HospitalInspections.org

Based on observation and record review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). The building was not equipped with an automatic sprinkler system. Findings include:

1. Observation and record review of the previous survey document revealed the building was a two story, unprotected, non-combustible, Type II (111) structure without an automatic sprinkler system.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

This deficiency has the potential to affect all patients and seven of seven smoke compartments.

Based on observation and interview, the provider failed to protect corridor openings with substantial doors, such as those constructed of 1¾ inch solid-bonded core wood or capable of resisting fire for at least twenty minutes. Five randomly observed doors at the south end on the second floor were hollow core doors. Findings include:

1. Observation at 11:30 a.m. revealed five doors on the south part of the second floor were hollow core doors. Interview with the director of maintenance at the time of the observation revealed he believed the doors were part of the original construction (the south part of the second floor was added later). He further revealed several staff members used the second floor to stay overnight occasionally.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

This deficiency has the potential to affect one of seven smoke compartments.

Based on observation and interview, the provider failed to ensure a vertical opening between floors was properly enclosed in one randomly observed location (the dumbwaiter elevator shaft). Findings include:

1. Observation at 1:30 p.m. on 4/5/16 revealed a dumbwaiter elevator shaft in the basement that was no longer being used for laundry services. The door into the dumbwaiter was left open creating a vertical opening between floors. That door should have remained closed when not in use to ensure the vertical shaft did not aid in the transfer of smoke and fire in the event of a fire situation.

Interview with the maintenance director at the time of the observation confirmed that condition. He indicated he was aware that unenclosed vertical openings between floors were not permitted. He indicated he did not recognize that dumbwaiter shaft as a vertical opening.

This deficiency has the potential to affect two of seven smoke compartments.

Based on observation and record review, the provider failed to maintain a protected path of egress from the second level to the exterior of the building. One of three stairs discharged onto the main level and was not provided with a one hour fire resistive enclosure to the exterior of the building. Findings include:

1. Observation at 11:15 a.m. revealed a second floor spiral stairs discharged into the dining room on the main level. Record review of the previous survey document dated 10/13/11 confirmed that finding. Those stairs were originally used by the nuns who operated the facility to access their dining room from the second level. Those stairs had existed since the building was constructed.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

This deficiency has the potential to affect one of seven smoke compartments.

Based on observation, record review, and interview, the provider failed to maintain conforming exit stairs. The south stair enclosure in the patient room wing had two storage rooms that opened into the stair enclosure. Findings include:

1. Observation at 10:30 a.m. revealed two storage rooms opened directly into the south stair enclosure in the patient room wings. Review of health department records revealed those two storage rooms had existed since the addition was constructed. That condition was confirmed by an interview with the director of maintenance.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

This deficiency has the potential to affect one of seven smoke compartments.

Based on observation and record review, the provider failed to maintain clear door widths of at least 32 inches for two randomly observed sets of exit access doors at the loading dock and at the service corridor. Findings include:

1. Observation at 10:45 a.m. revealed the leaves for the double-doors entering the loading dock area were only 24 inches wide and did not provide a clear opening width of 32 inches. The cross-corridor doors to the service corridor were also only 24 inches wide. Record review of the previous survey documents revealed those doors had existed since the building was constructed.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct deficiencies identified in K000.

This deficiency has the potential to affect one of seven smoke compartments.

Based on observation and record review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). The building was not equipped with an automatic sprinkler system. Findings include:

1. Observation revealed the building was a two story, unprotected, non-combustible, Type II (111) structure without an automatic sprinkler system. Review of the previous survey documents confirmed that finding.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

This deficiency has the potential to affect all patients and seven of seven smoke compartments.

Based on observation and interview, the provider failed to ensure all electrical equipment was tested and maintained in accordance with NFPA 70 National Electrical Code for two randomly observed electrical equipment components (line isolation monitors in the emergency room [ER] & operation room [OR]). Findings include:

1. Observation at 10:45 a.m. on 4/5/16 revealed and ER room with electrical outlets installed at the floor level next to the patient ER bed. That outlet was protected from electrical over-current with a line isolation monitor. Interview with the maintenance director at the time of the observation revealed he was unaware of what the electrical equipment was for. He did not indicate he was testing the equipment. That monitor should have been tested annually to ensure it was functioning correctly.

This deficiency has the potential to affect any patient using those rooms.

Based on observation and record review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). The building was not equipped with an automatic sprinkler system. Findings include:

1. Observation and record review of the previous survey document revealed the building was a two story, unprotected, non-combustible, Type II (111) structure without an automatic sprinkler system.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

This deficiency has the potential to affect all patients and seven of seven smoke compartments.

Based on observation and interview, the provider failed to protect corridor openings with substantial doors, such as those constructed of 1¾ inch solid-bonded core wood or capable of resisting fire for at least twenty minutes. Five randomly observed doors at the south end on the second floor were hollow core doors. Findings include:

1. Observation at 11:30 a.m. revealed five doors on the south part of the second floor were hollow core doors. Interview with the director of maintenance at the time of the observation revealed he believed the doors were part of the original construction (the south part of the second floor was added later). He further revealed several staff members used the second floor to stay overnight occasionally.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

This deficiency has the potential to affect one of seven smoke compartments.

Based on observation and interview, the provider failed to ensure a vertical opening between floors was properly enclosed in one randomly observed location (the dumbwaiter elevator shaft). Findings include:

1. Observation at 1:30 p.m. on 4/5/16 revealed a dumbwaiter elevator shaft in the basement that was no longer being used for laundry services. The door into the dumbwaiter was left open creating a vertical opening between floors. That door should have remained closed when not in use to ensure the vertical shaft did not aid in the transfer of smoke and fire in the event of a fire situation.

Interview with the maintenance director at the time of the observation confirmed that condition. He indicated he was aware that unenclosed vertical openings between floors were not permitted. He indicated he did not recognize that dumbwaiter shaft as a vertical opening.

This deficiency has the potential to affect two of seven smoke compartments.

Based on observation and record review, the provider failed to maintain a protected path of egress from the second level to the exterior of the building. One of three stairs discharged onto the main level and was not provided with a one hour fire resistive enclosure to the exterior of the building. Findings include:

1. Observation at 11:15 a.m. revealed a second floor spiral stairs discharged into the dining room on the main level. Record review of the previous survey document dated 10/13/11 confirmed that finding. Those stairs were originally used by the nuns who operated the facility to access their dining room from the second level. Those stairs had existed since the building was constructed.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

This deficiency has the potential to affect one of seven smoke compartments.

Based on observation, record review, and interview, the provider failed to maintain conforming exit stairs. The south stair enclosure in the patient room wing had two storage rooms that opened into the stair enclosure. Findings include:

1. Observation at 10:30 a.m. revealed two storage rooms opened directly into the south stair enclosure in the patient room wings. Review of health department records revealed those two storage rooms had existed since the addition was constructed. That condition was confirmed by an interview with the director of maintenance.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

This deficiency has the potential to affect one of seven smoke compartments.

Based on observation and record review, the provider failed to maintain clear door widths of at least 32 inches for two randomly observed sets of exit access doors at the loading dock and at the service corridor. Findings include:

1. Observation at 10:45 a.m. revealed the leaves for the double-doors entering the loading dock area were only 24 inches wide and did not provide a clear opening width of 32 inches. The cross-corridor doors to the service corridor were also only 24 inches wide. Record review of the previous survey documents revealed those doors had existed since the building was constructed.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the provider's intent to correct deficiencies identified in K000.

This deficiency has the potential to affect one of seven smoke compartments.

Based on observation and record review, the provider failed to meet the minimum construction standards of the 2000 Life Safety Code (LSC). The building was not equipped with an automatic sprinkler system. Findings include:

1. Observation revealed the building was a two story, unprotected, non-combustible, Type II (111) structure without an automatic sprinkler system. Review of the previous survey documents confirmed that finding.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

This deficiency has the potential to affect all patients and seven of seven smoke compartments.

Based on observation and interview, the provider failed to ensure all electrical equipment was tested and maintained in accordance with NFPA 70 National Electrical Code for two randomly observed electrical equipment components (line isolation monitors in the emergency room [ER] & operation room [OR]). Findings include:

1. Observation at 10:45 a.m. on 4/5/16 revealed and ER room with electrical outlets installed at the floor level next to the patient ER bed. That outlet was protected from electrical over-current with a line isolation monitor. Interview with the maintenance director at the time of the observation revealed he was unaware of what the electrical equipment was for. He did not indicate he was testing the equipment. That monitor should have been tested annually to ensure it was functioning correctly.

This deficiency has the potential to affect any patient using those rooms.