HospitalInspections.org

Based on observations it was determined that the east stairway is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.1.1. This deficient practice could affect all 15 patients, all staff and any visitors of the facility if a fire obstructs this stairway, blocking this exit.

Findings include:
Observations during the facility tour on August 28, 2013, between 09:30 am and 11:00 am, by surveyor 03006, revealed that the staff had the east exit stairway, basement level door blocked open and packages of salt are being stored in the lower level of the stairway.

The Director of Maintenance verified this finding during the facility tour and with the CEO during the exit conference.

Based on observations it was determined that the sprinkler system is not in accordance with NFPA 13 Standard for The Installation of Sprinkler Systems, 1999 edition. This deficient practice would allow a fire to extend above the suspended ceiling into a space that is not sprinkler protected, which will negatively impact all the residents, visitors and staff in these areas.

Findings include:
Observations during the facility tour on August 28, 2013, between 09:30 am and 11:00 am, by surveyor 03006, revealed that:

1) Some sprinkler heads have gaps around them as on the CT scan film room,
2) Some escutcheons are missing, and
3) There are missing ceiling tiles in various areas such as in the CT scan closet.

The Director of Maintenance verified these findings during the facility tour and with the CEO during the exit conference.

Based on observations it was determined that the east stairway is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.1.1. This deficient practice could affect all 15 patients, all staff and any visitors of the facility if a fire obstructs this stairway, blocking this exit.

Findings include:
Observations during the facility tour on August 28, 2013, between 09:30 am and 11:00 am, by surveyor 03006, revealed that the staff had the east exit stairway, basement level door blocked open and packages of salt are being stored in the lower level of the stairway.

The Director of Maintenance verified this finding during the facility tour and with the CEO during the exit conference.

Based on observations it was determined that the sprinkler system is not in accordance with NFPA 13 Standard for The Installation of Sprinkler Systems, 1999 edition. This deficient practice would allow a fire to extend above the suspended ceiling into a space that is not sprinkler protected, which will negatively impact all the residents, visitors and staff in these areas.

Findings include:
Observations during the facility tour on August 28, 2013, between 09:30 am and 11:00 am, by surveyor 03006, revealed that:

1) Some sprinkler heads have gaps around them as on the CT scan film room,
2) Some escutcheons are missing, and
3) There are missing ceiling tiles in various areas such as in the CT scan closet.

The Director of Maintenance verified these findings during the facility tour and with the CEO during the exit conference.