HospitalInspections.org

K14

Based on observation and/or review of records the facility failed to provide approved interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 2-15-11 at approximately 11:45am, by review of records with the Maintenance Director it was discovered as this facility was renovated within the past 5 years that interior finish materials such as wall coverings and ceiling tiles either lacked labels or documentation that supports their meeting the requirements as class A or B as rated materials. This applies to all areas of this facilities corridors and exit ways. These findings were verified with the Maintenance Director at the time of discovery.

K15

Based on observation and/or review of records the facility failed to provide minimum interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 2-15-11 at approximately 11:45am, by review of records with the Maintenance Director it was discovered as this facility was renovated within the past 5 years that interior finish materials such as resident room curtains, ceiling tiles and wall coverings either lacked labels or documentation that supports their meeting the requirements as class A or B rated materials. This applies to all areas, rooms, and spaces not used as corridors or exit ways. These findings were verified with the Maintenance Director at the time of discovery.

K21

Based upon observation and staff interview, it was determined that the facility failed to ensure proper operation of a smoke barrier door located in accordance with LSC, Section 19.2.2.2.6. This deficient practice could affect all occupants including residents, staff, and visitors. Findings Include:

On 2-15-11 at approximately 12:00pm, by observation and interview with the Maintenance Director it was discovered that on the 1st floor administration wing, the clean linen storage room corridor was being held open with a plastic bag wrapped around the door handle and secured to a storage rack, thus invalidating the doors self closing device. This finding was verified with the Maintenance Director at the time of discovery.

K-38

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.3. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 2-15-11, at approximately 10:40am, by observation and interview of the Maintenance Director, it was discovered that the north exit to grade does not provide a hard path to the public way thus there could be a potential obstruction to exiting. These findings were verified with the Maintenance Director at the time of discovery.

K45

Based upon observation and staff interview, illumination of means of egress, including exit discharge is arranged so that the failure of any single lighting fixture(bulb) will not leave the area in darkness outside the building to a public way or a distance away from the building that is considered safe in accordance with LSC 19.2.8. This deficient practice could affect all occupants including residents, staff, and visitors. Findings include:

On 2-15-11, at approximately 10:45am, by observation and interview of the Maintenance Director, it was discovered that the north exit to grade does not have illumination means to the public way and has only one, single light bulb fixture thus not meeting this requirement. These findings were verified with the Maintenance Director at the time of discovery.

K154

Based on record review and staff interview, the facility failed to implement a written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out-of-service for four or more hours in a 24 hour period in accordance with the LSC, section 9.7.6.1. This deficient practice could affect all residents, staff, and visitors. Findings include:

On 2-15-11 at approximately 11:58am, by review of records with the Maintenance Director it was discovered this facility does not have a written policy addressing a fire watch when the facilities fire suppression system is out of service for more than 4 hours. These findings were verified with the Maintenance Director at the time of discovery.

K155

Based on record review and staff interview, the facility failed to implement a written policy containing procedures to be followed in the event the fire alarm system has to be placed out-of-service for four or more hours in a 24 hour period in accordance with the LSC, section 9.6.1.8. This deficient practice could affect all residents, staff, and visitors. Findings include:

On 2-15-11 at approximately 11:55am, by review of records with the Maintenance Director it was discovered this facility does not have a written policy addressing a fire watch when the facilities fire alarm system is out of service for more than 4 hours. These findings were verified with the Maintenance Director at the time of discovery.