HospitalInspections.org

Based on observation and interview, the facility failed to meet building construction type requirements for one of three building levels.

Findings include:

Observation on February 13, 2024, at 9:13 a.m., revealed the ground floor MRI life safety drawings identified a two-hour rated wall separation to the pet scan area. The fire door, a part of the two-hour rated separation, was removed.

Interview with the maintenance director on February 13, 2024, at 9:13 a.m., confirmed the deficiency.

Based on observation and interview, the facility failed to maintain exit signage requirements for one of over ten exit signs.

Findings include:

Observation on February 13, 2024, at 9:26 a.m., revealed the basement exit sign light was not functioning at the time of the survey.

Interview with the maintenance technician on February 13, 2024, at 9:26 a.m., confirmed the exit sign was not illuminated.

Based on document review and interview, the facility failed to maintain cooking facilities in one of one main kitchen.

Findings include:

Document review on February 13, 2024, at 9:25 a.m., revealed the facility could not provide documentation for one of two semi-annual kitchen exhaust hood and duct cleanings. The last documented cleaning occurred on July 27, 2023.

Interview with the maintenance technician on February 13, 2024, at 9:25 a.m., confirmed the kitchen hood/duct cleaning deficiency.

Based on observation and interview, the facility failed to maintain smoke barrier wall requirements for two of three building levels.

Findings include:

Observation on February 13, 2024, between 9:09 a.m. and 10:55 a.m., revealed the following areas had open ceiling tiles that would allow the passage of smoke in the event of an emergency:
A. (9:09 a.m.) Basement boiler room;
B. (10:55 a.m.) First floor elevator room.

Interview with the maintenance director on February 13, 2024, at 10:55 a.m., confirmed the deficiencies.

Based on observation and interview, the facility failed to meet electrical system requirements for three of over ten electrical panels.

Findings include:

Observation on February 13, 2024, at 9:44 a.m., revealed the stairwell 11 electrical closet had open conductor slots in panels X, B, and C.

Reference: NFPA 70-408.7

Interview with the maintenance director on February 13, 2024, at 9: 44 am., confirmed the deficiencies.

Based on observation and interview, the facility failed to maintain receptacle requirements on two of three building levels.

Findings include:

Observation on February 13, 2024, between 9:01 a.m. and 10:40 a.m., revealed the following receptacles, located within six feet of a water source, were not protected by a ground fault circuit interrupter (GFCI) :
A. (9:01 a.m.) Basement boiler room sump pump area;
B. (10:40 a.m.) Second floor rehab sink area.

Interview with the maintenance technician and maintenance director on February 13, 2024, at 10:40 a.m., confirmed the areas were not protected by GFCIs.