HospitalInspections.org

Based upon observation and staff interview, it was determined that the facility failed to ensure the proper operation of the doors on the elevator control room in the basement, storage room next to tunnel door, Central Supply storage room and Med Surge storage room in accordance with the LSC, section 19.3.6.3.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 9/9/10 at approximately 11:00am, by observation and interview of the Maintenance Supervisor, the door on the elevator control room in the basement failed to close and latch properly when tested. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 11:01am, by observation and interview of the Maintenance Supervisor, the door on the storage room next to the tunnel door failed to close and latch properly when tested. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 11:50am, by observation and interview of the Maintenance Supervisor, the door on Central Supply storage room failed to close and latch properly when tested. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 12:05pm, by observation and interview of the Maintenance Supervisor, the door on the Med Surge storage room failed to close and latch properly when tested. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure the integrity of the smoke barrier walls in the Maintenance Room in the basement, old incinerator room, record storage room in the basement, storage room under stairs in the basement, smoke barrier wall at the Lab, smoke barrier wall at the Cafeteria Hall, smoke barrier wall at the Cardio Pulmonary Manager Office and in the Negative Pressure room in accordance with the LSC, section 19.3.7.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 9/9/10 at approximately 10:35am, by observation and interview of the Maintenance Supervisor, penetrations of the smoke barrier wall in the Maintenance Room in the basement failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 10:50am, by observation and interview of the Maintenance Supervisor, penetrations of the smoke barrier wall in the old incinerator room failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 11:15am, by observation and interview of the Maintenance Supervisor, penetrations of the smoke barrier wall in the record storage room in the basement failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 11:20am, by observation and interview of the Maintenance Supervisor, penetrations of the smoke barrier wall in the storage room under the stairs in the basement failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 11:25am, by observation and interview of the Maintenance Supervisor, penetrations of the smoke barrier wall at the Lab failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 11:26am, by observation and interview of the Maintenance Supervisor, penetrations of the smoke barrier wall at the Cafeteria Hall failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 11:56am, by observation and interview of the Maintenance Supervisor, penetrations of the smoke barrier wall at the Cardio Pulmonary Manager Office failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 12:03pm, by observation and interview of the Maintenance Supervisor, penetrations of the smoke barrier wall in the Negative Pressure room failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to provide and maintain the vertical opening protection of exits required by the LSC, section 19.2.1 and 19.3.1.1 by having rating labels painted on rated doors in the smoke barrier wall at the Lab. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 9/9/10 at approximately 11:23am, by observation and interview of the Maintenance Supervisor, the label on the rated door to the smoke barrier wall at the Lab was painted and the fire resistance of the door could not be determined. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure staff to be familiar with fire evacuation procedures in accordance with the LSC, section 19.7.1.2. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 9/9/10 at approximately 12:15pm, by observation and interview of the Maintenance Supervisor, the staff failed to remove an X-Ray machine from the corridor during fire alarm activation in the facility. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to ensure that the fire alarm system for the facility was inspected and tested in accordance with NFPA 72 (National Fire Alarm Code). This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 9/9/10 at approximately 9:55am, during record review and interview of the Maintenance Supervisor, the facility failed to have documentation of the annual testing of the facilities fire alarm system. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure that the automatic sprinkler system was inspected and tested in accordance with NFPA 13 and 25 by failing to remove wires that were attached to sprinkler pipe in the janitor closet by the Lab. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 9/9/10 at approximately 11:26am, by observation and interview of the Maintenance Supervisor, the facility failed to remove wires that were attached to sprinkler pipe in the janitor closet by Lab. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to have the kitchen hood suppression system inspected and tested in accordance with the LSC, section 19.3.2.6 and NFPA 96. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 9/9/10 at approximately 9:55am, during record review and interview of the Maintenance Supervisor, the facility failed to provide documentation of the required kitchen hood suppression system testing. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure the proper operation of the doors on the elevator control room in the basement, storage room next to tunnel door, Central Supply storage room and Med Surge storage room in accordance with the LSC, section 19.3.6.3.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 9/9/10 at approximately 11:00am, by observation and interview of the Maintenance Supervisor, the door on the elevator control room in the basement failed to close and latch properly when tested. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 11:01am, by observation and interview of the Maintenance Supervisor, the door on the storage room next to the tunnel door failed to close and latch properly when tested. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 11:50am, by observation and interview of the Maintenance Supervisor, the door on Central Supply storage room failed to close and latch properly when tested. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 12:05pm, by observation and interview of the Maintenance Supervisor, the door on the Med Surge storage room failed to close and latch properly when tested. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure the integrity of the smoke barrier walls in the Maintenance Room in the basement, old incinerator room, record storage room in the basement, storage room under stairs in the basement, smoke barrier wall at the Lab, smoke barrier wall at the Cafeteria Hall, smoke barrier wall at the Cardio Pulmonary Manager Office and in the Negative Pressure room in accordance with the LSC, section 19.3.7.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 9/9/10 at approximately 10:35am, by observation and interview of the Maintenance Supervisor, penetrations of the smoke barrier wall in the Maintenance Room in the basement failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 10:50am, by observation and interview of the Maintenance Supervisor, penetrations of the smoke barrier wall in the old incinerator room failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 11:15am, by observation and interview of the Maintenance Supervisor, penetrations of the smoke barrier wall in the record storage room in the basement failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 11:20am, by observation and interview of the Maintenance Supervisor, penetrations of the smoke barrier wall in the storage room under the stairs in the basement failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 11:25am, by observation and interview of the Maintenance Supervisor, penetrations of the smoke barrier wall at the Lab failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 11:26am, by observation and interview of the Maintenance Supervisor, penetrations of the smoke barrier wall at the Cafeteria Hall failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 11:56am, by observation and interview of the Maintenance Supervisor, penetrations of the smoke barrier wall at the Cardio Pulmonary Manager Office failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

On 9/9/10 at approximately 12:03pm, by observation and interview of the Maintenance Supervisor, penetrations of the smoke barrier wall in the Negative Pressure room failed to be properly sealed. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to provide and maintain the vertical opening protection of exits required by the LSC, section 19.2.1 and 19.3.1.1 by having rating labels painted on rated doors in the smoke barrier wall at the Lab. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 9/9/10 at approximately 11:23am, by observation and interview of the Maintenance Supervisor, the label on the rated door to the smoke barrier wall at the Lab was painted and the fire resistance of the door could not be determined. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure staff to be familiar with fire evacuation procedures in accordance with the LSC, section 19.7.1.2. This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 9/9/10 at approximately 12:15pm, by observation and interview of the Maintenance Supervisor, the staff failed to remove an X-Ray machine from the corridor during fire alarm activation in the facility. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to ensure that the fire alarm system for the facility was inspected and tested in accordance with NFPA 72 (National Fire Alarm Code). This deficient practice could affect all occupants including residents, staff and visitors.

Findings Include:

On 9/9/10 at approximately 9:55am, during record review and interview of the Maintenance Supervisor, the facility failed to have documentation of the annual testing of the facilities fire alarm system. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure that the automatic sprinkler system was inspected and tested in accordance with NFPA 13 and 25 by failing to remove wires that were attached to sprinkler pipe in the janitor closet by the Lab. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 9/9/10 at approximately 11:26am, by observation and interview of the Maintenance Supervisor, the facility failed to remove wires that were attached to sprinkler pipe in the janitor closet by Lab. This finding was verified with the Maintenance Supervisor at the time of discovery.

Based upon record review and staff interview, it was determined that the facility failed to have the kitchen hood suppression system inspected and tested in accordance with the LSC, section 19.3.2.6 and NFPA 96. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 9/9/10 at approximately 9:55am, during record review and interview of the Maintenance Supervisor, the facility failed to provide documentation of the required kitchen hood suppression system testing. This finding was verified with the Maintenance Supervisor at the time of discovery.