HospitalInspections.org

Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours. The deficient practice had the potential to affect 3 of 3 residents.
2 of 2 corridors has emergency lighting that is deficient.

Findings:

During the facility tour, between the hours of 9:00 am and 10:00 am observation revealed emergency lighting in the Dental Clinic on both hall not working.

Interview with life safety office stated that the lights where on order but had not arrived at this time.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility.

Findings:

During the facility tour, between the hours of 10:00 am and 12:00 PM observation revealed unsealed penetration at these locations. (1) Unsealed duct penetration inside respiratory therapy room, (2) Unsealed penetration inside emergency room admitting office at the top of the barrier wall, (3) Unsealed pipe penetration barrier wall inside triage room.

Based on visual observation the facility failed to assure that the smoke barrier doors in the facility properly protected the smoke compartment. The smoke barrier doors restrict the movement of smoke from one compartment to another.

Findings:

During the facility tour, between the hours of 1:00 PM and 2:00 PM observation revealed barrier doors not closing and latching into lobby.

Based on visual observation the facility failed to assure that the heating, ventilation and air conditioning system was installed in accordance with NFPA 90 A. The system could re-circulate smoke originating from one part of the building into other parts of the building otherwise unaffected. NFPA 101 9.2.2 / NFPA 91 Ventilating equipment standard for exhaust systems for conveying of vapors shall be incompliant with this standard.

Findings:

During the facility tour, between the hours of 11:00 am and 12:00 PM revealed ventilation of soiled room venting in to the attic space and possibly back into soiled room.