HospitalInspections.org

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Based on observation, the facility failed to maintain the means of egress per the requirements of:

2012 NFPA 101, 19.2.1, 7.1.10.1, and 7.2.1.5.1

This deficiency affects 1 of 2 loading dock doors.

Findings include:

During a tour of the facility, the surveyor observed a hasp with a a keyed padlock on the outside of the loading dock Kitchen Storage Room door.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to provide an exit sign per the requirements of:

2012 NFPA 101, 19.2.10.1, 7.10.1.2.1, 7.10.1.3, and 7.10.1.5.1

This deficiency affects the Central Purchasing Storage Room.

Findings include:

During a tour of the facility, the surveyor observed the facility failed to provide an exit sign for the rear exit door of the Central Purchasing Storage Room.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to provide documentation on the testing and inspection of the automatic sprinkler system per requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8
2011 NFPA 25, 5.1.1.2, Table 5.1.1.1.2, and 5.3.1.1.1

This deficiency affects entire facility.

Findings include:

During a tour of the facility, the facility failed to provide the following documentation:

1. The 2003 quick-response sprinkler heads found throughout the facility had been replaced or had a representative sample test completed within 20 years of installation.

2. The first quarterly automatic sprinkler inspection that was due in January of 2024

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to prohibit a portable space heating device per the requirements of:

2012 NFPA 101, 19.7.8

This deficiency affects 1 of 3 first floor smoke compartments.

Findings include:

During a tour of the facility, the surveyor observed a portable space heating device that was on the tile floor and not turned on. This device not was located in a sleeping smoke compartment. The facility was unable to provide documentation that the heating element did not exceeding 212 degrees.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to provide protection for the outside oxygen cylinder storage area per the requirements of:

2012 NFPA 99, 11.6.2.3 (11), 11.3.2.3, and 11.6.5.4

This deficiency affects the outside oxygen cylinder storage area.

Findings include:

During a tour of the facility, the surveyor obsrved the facility failed to provide protection for the outside oxygen cylinder storage area, against continuous exposure to direct rays of the sun where extreme temperatures prevail.

A member of the maintenance staff was present when this deficiency was identified.