HospitalInspections.org

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Based on observation, the facility failed to maintain the separation between construction types per the requirements of:

2012 NFPA 101, 19.1.3.5, and 8.2.1.3 (1)

This deficiency affects the only 2-hour fire barrier in this building.

Findings include:

During a tour of the facility, the surveyor observed the door between the Kitchen and Dining Room, in the 2-hour fire barrier separating Building 0103 and Building 0203, had a self-closing device but was propped open with a wood wedge and would not self-close in and emergency.

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 approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 12.1.2.2, 12.1.2.3, and 12.1.2.3.1

This deficiency affects the kitchen only.

Findings include:

During a tour of the facility, the surveyor observed that the facility failed to provide an approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location.

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

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Based on observation, the facility failed to provide ceilings required for the pendant sprinklers in the facility per the requirements of:

2012 NFPA 101, 19.3.6.2.4

This deficiency affects Laundry Room only .

Findings include:

During a tour of the facility, the surveyor observed four, 2' x 4' ceiling tiles missing in the folding area of Laundry Room.

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

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Based on observation, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, 8.5.6.3, and 8.5.4.4

This deficiency affects 2 of 3 smoke barriers.

Findings include:

During a tour of the facility, the surveyor observed the following:

1. On the 2nd floor, an unsealed 1/2" conduit being used as a cable chase for a gray cable above the ceiling over the cross-corridor doors (at room 230) of the smoke barrier between the Specialty Clinic Nursing Station and the Geri-psych Unit.

2. On the 3rd floor, an unsealed penetration of a 2" copper pipe above the ceiling over the cross-corridor doors (at the stairwell) of the smoke barrier between the ICU and MedSurg Units.

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 maintain the smoke dampers, combination smoke/fire dampers, and ceiling dampers per the requirements of:

2012 NFPA 101, 19.5.2.1, and 9.2.1
2012 NFPA 90A, 5.4.8.1, and 5.4.8.2
2010 NFPA 80, 19.4, and 19.5
2010 NFPA 105, 6.5.2

This deficiency affects the complete building.

Findings include:

During a tour of the facility, the facility failed to provide documentation of testing the smoke dampers, combination smoke/fire dampers, and ceiling dampers within the past 6 years.

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 maintain the smoke dampers, combination smoke/fire dampers, and ceiling dampers per the requirements of:

2012 NFPA 101, 19.5.2.1, and 9.2.1
2012 NFPA 90A, 5.4.8.1, and 5.4.8.2
2010 NFPA 80, 19.4, and 19.5
2010 NFPA 105, 6.5.2

This deficiency the complete building.

Findings include:

During a tour of the facility, the facility failed to provide documentation of testing the smoke dampers, combination smoke/fire dampers, and ceiling dampers within the past 6 years.

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

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Based on the review of documentation and interview, the facility failed to maintain the required fire doors in the two hour fire rated barrier separating the three story construction type II (222) from the one story construction type II (000) (not allowed in a three story building) per the requirements of:

2012 NFPA 101, 19.7.6, and 8.3.3.1
2010 NFPA 80, 5.2, and 5.2.3

This deficiency affects the Kitchen and Dining Room areas.

Findings include:

During a tour of the facility, the facility failed to provide documentation of its annual fire door inspection and testing within the past 12 months for the kitchen roll down fire assembly doors located in the two hour fire rated barrier separating the Kitchen from the Dining Room at the following locations:

1. At the dish collection window
2. In front of the Victory Warmer equipment

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

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Based on observation, the facility failed to maintain the Level 1 EES diesel emergency generator per the requirements of:

2012 NFPA 101, 19.2.9.1, and 7.9.2.4
2010 NFPA 110, 5.6.5.6, and 5.6.5.6.1

2012 NFPA 99, 6.5.4.1.1.2, and 6.4.4.1.1.3
2010 NFPA 110, 8.3.7.1, 8.4.2, 8.4.2.3, 8.3.8, and 8.3.4

This deficiency affects the only Level 1 EES diesel emergency generator .

Findings include:

During a tour of the facility, the facility failed to provide the following for the Level 1 EES diesel emergency generator :

1. A remote manual stop station of a type to prevent inadvertent or unintentional operation
2. A label for the remote manual stop station
3. The facility failed to provide the following documentation on the Level 1 EES diesel emergency generator:
a. Performing monthly testing on the battery for the past 12 months
b. The monthly 30 minute exercise failed to meet the requirements per 8.4.2 and the facility failed to provide documentation on an annual supplemental 1.5-hour load test per 8.4.2.3
c. Annual fuel quality test approved by ASTM standards

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

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Based on observation, the facility failed to maintain the Level 1 EES diesel generator per the requirements of:

2012 NFPA 101, 19.2.9.1, and 7.9.2.4
2010 NFPA 110, 5.6.5.6, and 5.6.5.6.1

2012 NFPA 99, 6.5.4.1.1.2, and 6.4.4.1.1.3
2010 NFPA 110, 8.3.7.1, 8.4.2.4, 8.3.8, 8.3.4 and 8.4.2.3

This deficiency affects the only Level 1 EES diesel emergency generator .

Findings include:

During a tour of the facility, the facility failed to provide the following for the Level 1 EES diesel emergency generator:

1. A remote manual stop station of a type to prevent inadvertent or unintentional operation
2. A label for the remote manual stop station
3. The facility failed to provide the following documentation on the Level 1 EES diesel emergency generator:
a. Performing monthly testing on the battery for the past 12 months
b. The monthly 30 minute exercise failed to meet the requirements per 8.4.2 and the facility failed to provide documentation on an annual supplemental 1.5-hour load test per 8.4.2.3
c. Annual fuel quality test approved by ASTM standards

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

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Based on observation, the facility failed to maintain the electrical equipment per the requirements of:

2012 NFPA 99, 10.2.3.6, and 10.2.4
2011 NFPA 70, 400.8 (1), (2), and (5)

This deficiency affects the first floor of this building.

Findings include:

During a tour of the facility, the surveyor observed an artificial Christmas tree with Christmas tree lights plugged in to an electrical extension cord that was installed above the ceiling and dropped down through the ceiling tile above the tree in the Main Lobby.

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