HospitalInspections.org

Based on observation and staff interview the facility fails to maintain the integrity of the building construction by allowing gaps around piping to remain open in walls and in ceiling areas. This deficient practice would allow fire products to spread to the auxillary areas, affecting 0 patients and all occupants in 1 of 12 smoke zones. This facility has a capacity of 49 and a census of 14.

Findings Include:

During the tour on 4/23/14 between 9:00 A.M. and 10:30 A.M. the following is observed:

1.) At approximately 9:45 A.M. it is discovered that there are missing ceiling tiles in the Basement exit corridor, near the Pharmacy.

2.) At approximately 10:00 A.M. it is discovered that there are open penetrations around piping in the Sprinkler Riser Room.

3.) At approximately 10:00 A.M. it is discovered that there are open gaps around a built-in cabinet structure in the room being used as storage in the Basement, near the Riser Room.

The Director of Facility Operations was present and acknowledged the findings.

NFPA Standard: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of NFPA 251. Fire barriers shall be continuous in accordance with 8.2.2.2. 2000 NFPA 101, 8.2.3.1.1

Based on observation and staff interview the facility fails to provide doors that are self-closing or automatically closing in a smoke barrier. The deficient practice of not providing self-closing or automatically closing doors in a smoke barrier would prevent the door from closing as required allowing smoke and fire product to spread beyond the smoke barrier more rapidly, affecting 0 patients and all occupants in 1 of 12 smoke zones. This facility has a capacity of 49 and a census of 14.

Findings Include:

During the tour on 4/23/14 between 9:00 A.M. and 10:30 A.M. the following is observed:

1.) At approximately 9:15 A.M. it is discovered that the 20-minute rated door leading from the exit corridor to the Tobin room is not self-closing.

2.) At approximately 9:40 A.M. it is discovered that the 20-minute rated door leading from the exit corridor to a storage room greater than 100 square feet in size is not self-closing.

The Director of Facility Operations was present and acknowledged the findings.

NFPA Standard: Requires doors in smoke barriers to be self-closing and have at least a 20-minute rating, 2000 NFPA 101, 19.3.7.6.

Based on observation and staff interview, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice would prevent these exits from being arranged so that they are readily available and accessible, affecting 0 patients and all occupants in 1 of 12 smoke zones. This facility has a capacity of 49 and a census of 14.

Findings Include:

During the tour on 4/23/14 between 9:00 A.M. and 10:30 A.M. the following is observed:

1.) At approximately 9:21 A.M. it is discovered that there is a deadbolt-style lock installed on a barrier door that requires greater the one operation to release the door in the Basement exit corridor, near the Pharmacy.

The Director of Facility Operations was present and acknowledged the findings.

NFPA Standard: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

Based on observation and staff interviews, the facility does not assure that the automatic fire sprinkler system is maintained properly. This deficient practice fails to prevent obstructions to spray patterns, affecting 0 patients and all occupants in 1 of 12 smoke zones. This facility has a capacity of 49 and a census of 14.

Findings Include:

During the tour on 4/23/14 between 9:00 A.M. and 10:30 A.M. the following is observed:

1.) At approximately 9:20 A.M. it is discovered that there are 2 sprinkler heads mounted within 18 inches of walls in the Tobin Room.

The Director of Facility Operations was present and acknowledged the finding.

NFPA Standard: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1.

Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede all occupants from exiting in the event of a fire or other emergency situation, affecting 0 patients and all occupants in 1 of 12 smoke zones. This facility has a capacity of 49 and a census of 14.

Findings Include:

During the tour on 4/23/14 between 9:00 A.M. and 10:30 A.M. the following is observed:

1.) At approximately 9:46 A.M. it is discovered that there are chairs and tables being stored in the Basement Exit Corridor near the Pharmacy and West Exit Stairwell.

The Director of Facility Operations was present and acknowledged the finding.

NFPA Standard: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress from, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1.

Based on observation and staff interview, the facility failed to assure that construction plans are properly submitted for review when changes are made to the building's sprinkler system. This deficiency may result in inaccurate installation of sprinkler components, affecting 0 patients and all occupants in 1 of 12 smoke zones. This facility has a capacity of 49 and a census of 14.

Findings Include:

During the tour on 4/23/14 between 9:00 A.M. and 10:30 A.M. the following is observed:

1.) At approximately 9:00 A.M. it is discovered that the facility had constructed a guest sleeping room in the Basement, including relocation of sprinkler heads without plans have been submitted to the Kansas State Fire Marshal for review.

The Director of Facility Operations was present and acknowledged the finding.

Based on observation and staff interview the facility fails to maintain the integrity of the building construction by allowing gaps around piping to remain open in walls and in ceiling areas. This deficient practice would allow fire products to spread to the auxillary areas, affecting 0 patients and all occupants in 1 of 12 smoke zones. This facility has a capacity of 49 and a census of 14.

Findings Include:

During the tour on 4/23/14 between 9:00 A.M. and 10:30 A.M. the following is observed:

1.) At approximately 9:45 A.M. it is discovered that there are missing ceiling tiles in the Basement exit corridor, near the Pharmacy.

2.) At approximately 10:00 A.M. it is discovered that there are open penetrations around piping in the Sprinkler Riser Room.

3.) At approximately 10:00 A.M. it is discovered that there are open gaps around a built-in cabinet structure in the room being used as storage in the Basement, near the Riser Room.

The Director of Facility Operations was present and acknowledged the findings.

NFPA Standard: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of NFPA 251. Fire barriers shall be continuous in accordance with 8.2.2.2. 2000 NFPA 101, 8.2.3.1.1

Based on observation and staff interview the facility fails to provide doors that are self-closing or automatically closing in a smoke barrier. The deficient practice of not providing self-closing or automatically closing doors in a smoke barrier would prevent the door from closing as required allowing smoke and fire product to spread beyond the smoke barrier more rapidly, affecting 0 patients and all occupants in 1 of 12 smoke zones. This facility has a capacity of 49 and a census of 14.

Findings Include:

During the tour on 4/23/14 between 9:00 A.M. and 10:30 A.M. the following is observed:

1.) At approximately 9:15 A.M. it is discovered that the 20-minute rated door leading from the exit corridor to the Tobin room is not self-closing.

2.) At approximately 9:40 A.M. it is discovered that the 20-minute rated door leading from the exit corridor to a storage room greater than 100 square feet in size is not self-closing.

The Director of Facility Operations was present and acknowledged the findings.

NFPA Standard: Requires doors in smoke barriers to be self-closing and have at least a 20-minute rating, 2000 NFPA 101, 19.3.7.6.

Based on observation and staff interview, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice would prevent these exits from being arranged so that they are readily available and accessible, affecting 0 patients and all occupants in 1 of 12 smoke zones. This facility has a capacity of 49 and a census of 14.

Findings Include:

During the tour on 4/23/14 between 9:00 A.M. and 10:30 A.M. the following is observed:

1.) At approximately 9:21 A.M. it is discovered that there is a deadbolt-style lock installed on a barrier door that requires greater the one operation to release the door in the Basement exit corridor, near the Pharmacy.

The Director of Facility Operations was present and acknowledged the findings.

NFPA Standard: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

Based on observation and staff interviews, the facility does not assure that the automatic fire sprinkler system is maintained properly. This deficient practice fails to prevent obstructions to spray patterns, affecting 0 patients and all occupants in 1 of 12 smoke zones. This facility has a capacity of 49 and a census of 14.

Findings Include:

During the tour on 4/23/14 between 9:00 A.M. and 10:30 A.M. the following is observed:

1.) At approximately 9:20 A.M. it is discovered that there are 2 sprinkler heads mounted within 18 inches of walls in the Tobin Room.

The Director of Facility Operations was present and acknowledged the finding.

NFPA Standard: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1.

Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede all occupants from exiting in the event of a fire or other emergency situation, affecting 0 patients and all occupants in 1 of 12 smoke zones. This facility has a capacity of 49 and a census of 14.

Findings Include:

During the tour on 4/23/14 between 9:00 A.M. and 10:30 A.M. the following is observed:

1.) At approximately 9:46 A.M. it is discovered that there are chairs and tables being stored in the Basement Exit Corridor near the Pharmacy and West Exit Stairwell.

The Director of Facility Operations was present and acknowledged the finding.

NFPA Standard: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress from, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1.

Based on observation and staff interview, the facility failed to assure that construction plans are properly submitted for review when changes are made to the building's sprinkler system. This deficiency may result in inaccurate installation of sprinkler components, affecting 0 patients and all occupants in 1 of 12 smoke zones. This facility has a capacity of 49 and a census of 14.

Findings Include:

During the tour on 4/23/14 between 9:00 A.M. and 10:30 A.M. the following is observed:

1.) At approximately 9:00 A.M. it is discovered that the facility had constructed a guest sleeping room in the Basement, including relocation of sprinkler heads without plans have been submitted to the Kansas State Fire Marshal for review.

The Director of Facility Operations was present and acknowledged the finding.