HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure 2 of 2 fire barrier walls were continuous from floor to ceiling. The findings were:

1. Observation of the Lab/X-Ray fire barrier on 4/30/13 at 9:20 AM showed 1 of the 2 double doors was not able to fully latch into the door frame under the power of the installed self-closing device. At the time of the observation the director of facilities and engineering could not explain why the door was not observed and modified during the monthly safety inspections.

2. Observation of the nursing home fire barrier wall on 4/30/13 at 9:53 AM showed three unsealed pipe penetrations in the ceiling cavity above the activities office. The largest gap measured 3 inches across. At the time of the observation the director of facilities and engineering could not explain why the wall penetrations were not observed and repaired during the quarterly safety inspections.

Based on observation and staff interview, the facility failed to ensure corridor doors were smoke resistant in 1 of 2 smoke compartments. The findings were:

Observation on 4/30/13 at 8:30 AM and 9 AM showed the following corridor doors were not provided with a latch bolt, each door was provided with a dead bolt latch:
a. The central processing corridor door was also provided with a self-closing device.
b. The corridor door to Doctor Hills office.
c. The corridor door to the restroom between patient room #10 and #11.
On 4/30/13 at 8:35 AM the director of facilities and engineering, reported the aforementioned doors were originally installed in 1956. He assumed a dead bolt latch was adequate. He was unaware an automatic latching mechanism was required on all corridor doors.

Based on observation and staff interview, the facility failed to ensure the smoke barrier wall was continuous from floor to ceiling. The findings were:

Observation of the smoke barrier wall on 4/30/13 at 9:48 AM showed a ? inch cable penetration above the east set of double doors. At the time of the observation the director of facilities and engineering could not explain why the aforementioned hole was not noticed and repaired during the quarterly safety inspections.

Based on observation and staff interview, the facility failed to ensure 2 of 2 fire barrier walls were continuous from floor to ceiling. The findings were:

1. Observation of the Lab/X-Ray fire barrier on 4/30/13 at 9:20 AM showed 1 of the 2 double doors was not able to fully latch into the door frame under the power of the installed self-closing device. At the time of the observation the director of facilities and engineering could not explain why the door was not observed and modified during the monthly safety inspections.

2. Observation of the nursing home fire barrier wall on 4/30/13 at 9:53 AM showed three unsealed pipe penetrations in the ceiling cavity above the activities office. The largest gap measured 3 inches across. At the time of the observation the director of facilities and engineering could not explain why the wall penetrations were not observed and repaired during the quarterly safety inspections.

Based on observation and staff interview, the facility failed to ensure corridor doors were smoke resistant in 1 of 2 smoke compartments. The findings were:

Observation on 4/30/13 at 8:30 AM and 9 AM showed the following corridor doors were not provided with a latch bolt, each door was provided with a dead bolt latch:
a. The central processing corridor door was also provided with a self-closing device.
b. The corridor door to Doctor Hills office.
c. The corridor door to the restroom between patient room #10 and #11.
On 4/30/13 at 8:35 AM the director of facilities and engineering, reported the aforementioned doors were originally installed in 1956. He assumed a dead bolt latch was adequate. He was unaware an automatic latching mechanism was required on all corridor doors.

Based on observation and staff interview, the facility failed to ensure the smoke barrier wall was continuous from floor to ceiling. The findings were:

Observation of the smoke barrier wall on 4/30/13 at 9:48 AM showed a ? inch cable penetration above the east set of double doors. At the time of the observation the director of facilities and engineering could not explain why the aforementioned hole was not noticed and repaired during the quarterly safety inspections.