HospitalInspections.org

The inspector observed, while accompanied by clinical surveyors and the director of nursing on 05/07/2024 that the door to the seclusion room 105E was not latching properly. Also control access badge was not functional and we were involuntary locked inside seclusion room.

(C) Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each facility. The physical premises of the facility and those areas of the facility's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and subchapters F and G of this chapter. §134.122 (d)(1)(C)

The inspector observed, while accompanied by the Director of Plant Operations on 05/08/2024 that verification of the existing roofing system is needed to ensure it meets the requirement for building Type II (111).

The inspector observed, while accompanied by the Director of Plant Operations 05/07/2024 suite separation noted on LS plan were not physically noted on existing walls.

The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 the access door from Lab TLT 132E to Lab 133E, penetrates a 1 Hr. wall. The panel did not bear an UL listing label. (Lab 133E needs not to be rated)

"Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device." - NFPA 101, 2003, 8.3.5.1.




The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that none of the 1 hr. smoke barrier and 1hr. fire barrier walls as indicated on life safety plans not stenciled on site. It was very difficult to track the delineation of the noted smoke compartments and plan noted rated walls. It is expected for the facility to track and stencil the smoke compartment walls as well as all other rated walls in the facility. While performing this task, seal and caulk any wall penetrations that are non-compliant.

All fire walls, fire barriers, fire partitions, smoke barriers, and smoke partitions shall be effectively and permanently identified with signs or stenciling per IBC 2012 section 703.7.



The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that the facility failed to provide a legible Life Safety Plan. Facility shall keep a large scale (24" x 36" min.) LS plan.

§133.167 (f)(2)(B) Fire safety plans. These drawings shall be provided for all newly constructed buildings, conversions of existing buildings for facilities, additions to existing licensed facilities, and remodeled portions of existing buildings containing licensed facilities. Fire safety plans shall be of a sufficiently large-scale to clearly illustrate the proposed design but not less than one-sixteenth inch equals one foot and shall include the following information:


(i) separate fire safety plans (preferably one floor plan per sheet) shall indicate location of fire protection rated walls and partitions, location and fire resistance rating of each fire damper, and the required means of egress (corridors, stairs, exits, exit passageways);

(I) when a new building is to contain a proposed facility, when an existing building is converted to a facility, or when an addition is made to an existing facility building, plans of each floor and roof shall be provided.

(II) when a portion of a building is remodeled or when a new service is added, only the plan of the floor where the remodeling will take place or new service will be introduced and the plan of the floor of discharge shall be provided.

(ii) designated smoke compartments with floor areas of each compartment, location and fire resistance rating (one or two hour) of each smoke partition, location, type and fire resistance rating of each smoke damper.

(iii) location of all required fire alarm devices, including all fire alarm control panels, manual pull stations, audible and visual fire alarm signaling devices, smoke detectors (ceiling and duct-mounted), fire alarm annunciators, fire alarm transmission devices, fire sprinkler flow switches and control valve supervisory switches on each of the floor plans; and

(iv) areas protected with fire sprinkler systems (pendant, sidewall or upright, normal or quick response, and temperature rating shall be indicated), standpipe system risers and sizes with valves and inside and outside fire department connections, fire sprinkler risers and sizes, location and type of portable fire extinguishers.

The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that the facility failed properly to discern in the field where the subdivision for the required smoke compartments occurred.

The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that the facility failed to provide proper elevation location for the outside air intakes located at the roof AHU's.

(IV) Low air intake location limit. The bottom of outside air intakes serving central systems shall be located as high as practical but at least six feet above ground level, or if installed above the roof, three feet above the roof level (facility to verify all roof top units outside air intake locations). §134.122 (d)(2)(B)(IV)



The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 and 05/08/2024 while inspecting the AHU located on the roof and while checking documents, that the units did not provide required smoke duct detectors.

NFPA 90A, 6.4.2.1 Smoke detectors listed for use in air distribution systems shall be located as follows: (1) Downstream of the air filters and ahead of any branch connections in air supply systems having a capacity greater than 944 L/sec (2000 ft3/min) , (2) At each story prior to the connection to a common return and prior to any recirculation or fresh air inlet connection in air return systems having a capacity greater than 7080 L/sec (15,000 ft3/min) and serving more than one story
Smoke detectors shall be installed in return air systems with a design capacity greater than 2,000 cfm (0.9 m3/s), in the return air duct or plenum upstream of any filters, exhaust air connections, outdoor air connections, or decontamination equipment and appliances. IBC 2015 606.2.1



The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that all the patient care showers failed to provide proper moisture resistant finish as required.

§134.122 (d)(2)(B)(iv)
(iv) Wall finishes. Wall finishes shall be smooth, washable, moisture resistant, and cleanable by standard housekeeping practices. Wall finishes shall comply with requirements contained in Table 2 of §134.131(b) of this title, and NFPA 101, §18-3.3.

(I) Wall finishes shall be water resistant in the immediate area of plumbing fixtures.

(II) Wall finishes in areas subject to frequent wet cleaning methods shall be impervious to water, tightly sealed and without voids.

The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that a patient's room shower stall had two towels laying on the shower floor. At time of inspection this condition did not provide a safe environment for the patient.

(C) Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each facility. The physical premises of the facility and those areas of the facility's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and subchapters F and G of this chapter. §134.122 (d)(1)(C)




The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that the electrical room was also being used for storage.

"Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage." - NFPA 70, 2012, 110.26(E)




The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that the sprinkler heads inside the kitchen freezer were not protected against mechanical injury.

NFPA 13 2010 - 6.2.8? Guards. Sprinklers subject to mechanical injury shall be protected with listed guards.





The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that ceiling requirements were not met for the following rooms:

NFPA 13 2010 - 6.2.8? Guards. Sprinklers subject to mechanical injury shall be protected with listed guards.





The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that ceiling requirements were not met for the following rooms:

(v) The ceiling in the food storage room and soiled and clean ware cleaning area shall be of the monolithic type as required by §134.122(d)(2)(B)(vi)(III).

(B) Ceilings in soiled workrooms and secure holding rooms shall be of the monolithic type as required by §134.122(d)(2)(B)(vi)(III) of this title.





The inspector observed, while accompanied by the Director of Plant Operations, clinical surveyor, and director of nursing on 05/07/2024 that ceiling requirements were not met. Portions of the ceiling grid in certain areas of kitchen had what looked like black blotches. Facility should have those tested to determine if mold is present within kitchen ceiling.

(iv) The ceiling in food preparation and food assembly areas shall be washable as required by §134.122(d)(2)(B)(vi)(II).

(C) Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each facility. The physical premises of the facility and those areas of the facility's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and subchapters F and G of this chapter. §134.122 (d)(1)(C)






The inspector observed, while accompanied by the Director of Plant Operations, 05/08/2024 that the facility failed to provide
Logs for each air handler showing dates when final filters, filter bed no. 2, have been replaced with the pressure differential across the filter before and after filter replacement where differential pressure monitors are required. (ASHRAE 170, Informative Appendix A, Operations and Maintenance Procedures.)



The inspector observed, while accompanied by the Director of Plant Operations, 05/07/2024 that there was accumulated moisture in the ceilining of the isolation rooms. Determine if humidifiers needed and comply with below.

(IX) Humidifier location. When duct humidifiers are located upstream of the final filters, they shall be located at least 15 feet from the filters. Ductwork with duct-mounted humidifiers shall be provided with a means of removing water accumulation. An adjustable high-limit humidistat shall be located downstream of the humidifier to reduce the potential of condensation inside the duct. All duct take-offs should be sufficiently downstream of the humidifier to ensure complete moisture absorption. Reservoir-type water spray or evaporative pan humidifiers shall not be used. 134.122 (d)(3)(E)(IX)

The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that the facility failed properly maintain low voltage wires of the existing ceiling grid.

Support wires and associated fittings that provide secure support and that are installed in addition to the ceiling grid support wires shall be permitted as the sole support. Where independent support wires are used, they shall be secured at both ends. Cables and raceways shall not be supported by ceiling grids." - NFPA 70, 2011, 300.11

The inspector observed, while accompanied by the Director of Plant Operations on 05/08/2024 that the facility failed to provide documented performance data forboth hospital and non-hospital receptacles.

A.16. Receptacles shall be tested for:
1) The physical integrity of each receptacle shall be confirmed by visual inspection.
2) The continuity of the grounding circuit in each electrical receptacle shall be verified.
3) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
4) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). (NFPA 99, 6.3.3.2)

The inspector observed, while accompanied by the Director of Plant Operations on 05/07/2024 that the facility failed properly to identify required life safety branch requirements at the generator site.

6.4.2.2.3.2 "The life safety branch shall supply power for lighting, receptacles, and equipment as follows:
(1) Illumination of means of egress in accordance with 101, Life Safety Code,
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code,
(3) Hospital communications systems, where used for issuing instruction during emergency conditions,
(4) Generator set locations as follows:
(a) Task illumination,
(b) Battery charger for emergency battery-powered lighting unit(s),
(c) Select receptacles at the generator set location and essential electrical system transfer switch locations,