HospitalInspections.org

Based on observation and interview with facility staff the facility failed to ensure proper protection for 3 of 3 spaces open to the corridor. In the event of a fire all 25 clients may be affected.

Findings Include:

On 06-27-12 at 10:40 a.m. observation revealed the vending room and the outpatient registration waiting areas are open to the corridor and the facility is not provided with listed quick response sprinklers or a complete automatic smoke detection system.
At 12:45 p.m. on 06-27-12 observation also revealed the pass through window at the lobby has a permanent opening that cannot be closed.


At the time of observation on 06-27-12 staff member M stated he thought adding a smoke detector to the affected rooms would be in compliance.

Based on observation and interview with facility staff the facility failed to ensure doors opening onto the corridor will resist the passage of smoke. In the event of a fire all 25 residents may be affected.

Findings Include:

On 06-27-12 between 11:00 a.m. and 1:30 p.m. observation revealed the following room doors opening to the corridor did not seal tight in the frame and left a 1/4 to 1/2 inch gap at the top and/or sides:
1. Rehab door 101
2. Central Supply
Observation between 11:00 a.m. and 1:30 p.m. on 06-27-12 also revealed the following doors are not positive latching:
1. D.O.N. office door
2. The Ultra-sound room door
3. The dressing room door

At the time of observation staff member M stated the facility doors were getting older and required regulars checks to ensure they seal properly when closed.

Based on observation and interview with facility staff the facility failed to ensure doors to hazardous rooms will resist the passage of smoke. In the event of a fire all 25 residents may be affected.

Findings Include:

On 06-27-12 between 10:45 a.m. and 1:30 p.m. observation revealed the following doors were not self closing:
1. The Kitchen Storage room door
2. The Pharmacy Storage room door
On 06-27-12 between 10:45a.m. and 1:30 p.m. observation also revealed the following doors to hazardous areas were not positive latching:
1. The Education Storage
2. HR Admin Storage
3. Laboratory

At the time of observation on 06-27-12 staff member M stated the facility believed dead bolt locks were acceptable for the locations.

Based on observation and interview with facility staff the facility failed to ensure exits are readily accessible at all times . In the event of a fire all 25 clients may be affected.

Findings Include:

On 06-27-12 between 10:30 a.m. and 1:30 p.m. observation revealed openings in guard rails at stair and ramp landings have openings that are larger than those that would allow a 6 inch sphere to pass thru and the guard rails at the Outpatient North Exit are temporary chains. Handrails at these locations are not provided with a return bend at the top to prevent objects from hanging on them.
At 1:15 p.m. on 06-27-12 observation also revealed the ramp at the Outpatient North Exit is steeper than 1:10.

During the exit interview on 06-27-12 staff member A stated the facility was constructed in the 1930's and the requirements have changed.

Based on observation and interview with facility staff the facility failed to ensure total sprinkler protection. In the event of a fire in the nonsprinklered areas all 25 clients may be affected.

Findings Include:

On 06-27-12 at 12:15 p.m. observation revealed the East exit overhang is greater than 4 feet wide with combustible construction and is not sprinkler protected.
At 1:15 p.m. observation also revealed sprinklers in the Outpatient Registration office are less than 6 feet apart.

At the time of observation on 06-27-12 staff member M stated the facility was unaware of the overhang requirements and a wall had been moved in the Outpatient Office.

Based on observation and interview with facility staff the facility failed to ensure proper protection for 3 of 3 spaces open to the corridor. In the event of a fire all 25 clients may be affected.

Findings Include:

On 06-27-12 at 10:40 a.m. observation revealed the vending room and the outpatient registration waiting areas are open to the corridor and the facility is not provided with listed quick response sprinklers or a complete automatic smoke detection system.
At 12:45 p.m. on 06-27-12 observation also revealed the pass through window at the lobby has a permanent opening that cannot be closed.


At the time of observation on 06-27-12 staff member M stated he thought adding a smoke detector to the affected rooms would be in compliance.

Based on observation and interview with facility staff the facility failed to ensure doors opening onto the corridor will resist the passage of smoke. In the event of a fire all 25 residents may be affected.

Findings Include:

On 06-27-12 between 11:00 a.m. and 1:30 p.m. observation revealed the following room doors opening to the corridor did not seal tight in the frame and left a 1/4 to 1/2 inch gap at the top and/or sides:
1. Rehab door 101
2. Central Supply
Observation between 11:00 a.m. and 1:30 p.m. on 06-27-12 also revealed the following doors are not positive latching:
1. D.O.N. office door
2. The Ultra-sound room door
3. The dressing room door

At the time of observation staff member M stated the facility doors were getting older and required regulars checks to ensure they seal properly when closed.

Based on observation and interview with facility staff the facility failed to ensure doors to hazardous rooms will resist the passage of smoke. In the event of a fire all 25 residents may be affected.

Findings Include:

On 06-27-12 between 10:45 a.m. and 1:30 p.m. observation revealed the following doors were not self closing:
1. The Kitchen Storage room door
2. The Pharmacy Storage room door
On 06-27-12 between 10:45a.m. and 1:30 p.m. observation also revealed the following doors to hazardous areas were not positive latching:
1. The Education Storage
2. HR Admin Storage
3. Laboratory

At the time of observation on 06-27-12 staff member M stated the facility believed dead bolt locks were acceptable for the locations.

Based on observation and interview with facility staff the facility failed to ensure exits are readily accessible at all times . In the event of a fire all 25 clients may be affected.

Findings Include:

On 06-27-12 between 10:30 a.m. and 1:30 p.m. observation revealed openings in guard rails at stair and ramp landings have openings that are larger than those that would allow a 6 inch sphere to pass thru and the guard rails at the Outpatient North Exit are temporary chains. Handrails at these locations are not provided with a return bend at the top to prevent objects from hanging on them.
At 1:15 p.m. on 06-27-12 observation also revealed the ramp at the Outpatient North Exit is steeper than 1:10.

During the exit interview on 06-27-12 staff member A stated the facility was constructed in the 1930's and the requirements have changed.

Based on observation and interview with facility staff the facility failed to ensure total sprinkler protection. In the event of a fire in the nonsprinklered areas all 25 clients may be affected.

Findings Include:

On 06-27-12 at 12:15 p.m. observation revealed the East exit overhang is greater than 4 feet wide with combustible construction and is not sprinkler protected.
At 1:15 p.m. observation also revealed sprinklers in the Outpatient Registration office are less than 6 feet apart.

At the time of observation on 06-27-12 staff member M stated the facility was unaware of the overhang requirements and a wall had been moved in the Outpatient Office.