HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that the facility failed to provide a log indicating compliance on FLAME SPREAD RATINGS for interior finishes on surfaces other than concrete, plaster, or gypsum board at Corridor / Lobby floors, walls, and ceilings.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that the facility failed to provide the required rating for the cross-corridor door opening in the 1 hour fire/smoke rated SMOKE COMPARTMENT partition.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that the facility failed to provide a log indicating compliance with requirement for monthly testing by staff of the fire alarm system and its automatic signal response. Additionally, while it appeared that the facility had accomplished yearly inspections, their documentation was incomplete, and not logged in a systematic fashion.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that while it appears the facility had accomplished some yearly inspections required for the fire sprinkler system, the facility failed to provide a log indicating consistant and routine compliance of such.

Additionally, in the RADIOLOGY ROOM the following issues found were not in compliance:
Area of room near door to Corridor was missing a sprinkler head.
Area of room near X-ray Technician screen wall was also missing a sprinkler head.
The sprinkler head near the TOILET wall was not a minimum of 4 inches off the wall.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that while it appears the facility had accomplished some yearly inspections required for all fire extinguishers, the facility failed to provide a comprehensive log indicating consistant and routine compliance of such.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that the facility failed to provide a log indicating compliance on FLAME RETARDANT PROPERTIES of drapes, curtains, including cubicle curtains, mattresses and upholstered furniture.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to provide logs indicating consistant, systematic compliance on the following issues and items:

1. Air filter change log.
2. Electrical equipment inspections - Biomedical.
Critical Areas: Semi-annually.
General Areas: Annually
3. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually

Additionally, the facility failed regarding the following:
4. The required Emergency Generator Set (task illumination & receptacle) were missing.
5. In the EMERGENCY PATIENT HOLDING area there were accordian folding partitions and cubicle curtains from floor to ceiling that blocked the spray pattern of ceiling mounted fire sprinklers.
6. In the CT SCAN room there was a cubicle curtain from floor to ceiling that blocked the spray pattern of ceiling mounted fire sprinkler(s).
7. In the SURGICAL ANNESTHESIA STORAGE ROOM the required 18 inch clear zone below sprinkler heads was not provided.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that the facility failed to provide an Emergency Generator log indicating consistant, systematic compliance on the following issues and items:

1. Weekly inspections.
2. Monthly load tests.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that the facility failed to provide a log indicating compliance on FLAME SPREAD RATINGS for interior finishes on surfaces other than concrete, plaster, or gypsum board at Corridor / Lobby floors, walls, and ceilings.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that the facility failed to provide the required rating for the cross-corridor door opening in the 1 hour fire/smoke rated SMOKE COMPARTMENT partition.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that the facility failed to provide a log indicating compliance with requirement for monthly testing by staff of the fire alarm system and its automatic signal response. Additionally, while it appeared that the facility had accomplished yearly inspections, their documentation was incomplete, and not logged in a systematic fashion.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that while it appears the facility had accomplished some yearly inspections required for the fire sprinkler system, the facility failed to provide a log indicating consistant and routine compliance of such.

Additionally, in the RADIOLOGY ROOM the following issues found were not in compliance:
Area of room near door to Corridor was missing a sprinkler head.
Area of room near X-ray Technician screen wall was also missing a sprinkler head.
The sprinkler head near the TOILET wall was not a minimum of 4 inches off the wall.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that while it appears the facility had accomplished some yearly inspections required for all fire extinguishers, the facility failed to provide a comprehensive log indicating consistant and routine compliance of such.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that the facility failed to provide a log indicating compliance on FLAME RETARDANT PROPERTIES of drapes, curtains, including cubicle curtains, mattresses and upholstered furniture.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to provide logs indicating consistant, systematic compliance on the following issues and items:

1. Air filter change log.
2. Electrical equipment inspections - Biomedical.
Critical Areas: Semi-annually.
General Areas: Annually
3. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually

Additionally, the facility failed regarding the following:
4. The required Emergency Generator Set (task illumination & receptacle) were missing.
5. In the EMERGENCY PATIENT HOLDING area there were accordian folding partitions and cubicle curtains from floor to ceiling that blocked the spray pattern of ceiling mounted fire sprinklers.
6. In the CT SCAN room there was a cubicle curtain from floor to ceiling that blocked the spray pattern of ceiling mounted fire sprinkler(s).
7. In the SURGICAL ANNESTHESIA STORAGE ROOM the required 18 inch clear zone below sprinkler heads was not provided.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that the facility failed to provide an Emergency Generator log indicating consistant, systematic compliance on the following issues and items:

1. Weekly inspections.
2. Monthly load tests.