HospitalInspections.org

Based on observation and interview it was determined the facility failed to provide an acceptable type of building construction affecting six of six floors in this component

Findings include:

1. Observation on January 5, 2017, at 10:15 AM revealed the 6 story building was constructed as an unprotected non-combustible structure, which exceeds the maximum allowable story height for this type of construction by four stories.

Interview with Facility Representative #1 on January 5, 2017, at 10:16 AM confirmed the structure exceeded the maximum allowable story height for this type of construction.

Based on observation and interview, it was determined the facility exceeded the maximum allowable story height for this type of construction, affecting five of five floors in this component.

Findings include:

1. Observation on January 5, 2017, between 9:30 AM and 11:45 AM, revealed the facility exceeded the maximum allowable story height for a protected ordinary construction, structure by three stories.

Exit interview with maintenance representative #1 and maintenance representative #2, on January 5, 2017, between 11:45 AM and 12:00 PM, confirmed the facility exceeded the maximum allowable story height for this type of construction.

Based on observation and interview it was determined the facility failed to maintain door openings in one instance affecting one of nine floors within the facility.

Findings include:

1. Observation on January 3, 2017, at 10:20 AM revealed the 7th floor smoke barrier door was equipped with latching hardware, which was inoperable.

Interview with facility representative #1, on January 3, 2017, at 10:21 AM confirmed the inoperable door hardware.

Based on observation and interview, it was determined the facility failed to maintain exit access corridors on one of six levels in this component.

Findings include:

1. Observation on January 5, 2017, between 9:30 AM and 11:45 AM, revealed the basement-level exit access corridor had reduced headroom, which measured six feet, three inches, from finished floor to overhead protrusion.

Exit interview with maintenance representative #1 and maintenance representative #2, on January 5, 2017, between 11:45 AM and 12:00 PM, confirmed the basement-level exit access corridor headroom was less than the required six feet, eight inches.

Based on observation and interview, it was determined the facility failed to maintain multiple vertical enclosures affecting five of five floors in this component.

Findings include:

1. Observation on January 5, 2017, between 9:30 AM and 11:45 AM, revealed vertical enclosures, including elevator shafts and exit stair tower ceilings had exposed metal lathe. Shafts lacked the required two hour fire resistance rating.

Exit interview with maintenance representative #1 and maintenance representative #2, on January 5, 2017, between 11:45 AM and 12:00 PM, confirmed the vertical enclosures were not protected with the required hourly fire resistance rating.

Based on observation and interview it was determined the facility failed to maintain corridor doors affecting one of nine floors within the facility.

Findings include:

1. Observation on January 3, 2017, at 11:10 AM revealed the 7th floor, resident room door #701 could not close and latch.

Interview with facility representative #1, on January 3, 2017, at 11:12 AM confirmed the damaged corridor door.

Based on documentation review, observation, and interview it was determined the facility failed to maintain/provide smoking provisions affecting the entire facility.

Findings include:

1. Review of documentation and observation on January 5, 2017, at 10:05 AM revealed the facility has a tobacco free policy on file, and a designated smoking area located near an exit outside.

Interview with Facility Representative #1 on January 5, 2017, at 10:06 AM confirmed the smoking provision deficiency.