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Tag No.: K0011
Based on observation the facility failed to provide an acceptable 2 hour occupancy separation between the hospital and the nursing home. The inspector observed while accompanied by the Environmental Services Director, and health care consultant's District Manager during the hours of the inspection from 11:00 am to 3:00 pm, that there were multiple unsealed piping penetrations identified at multiple locations in the 2 hour wall separating the hospital and nursing home facilities.
LOCATION 'A' : (penetrations were identified from the Nursing Home side)
Three unsealed penetrations were located above the tub / lavatory of the Patient Toilet for Nursing Home Patient Room 407.
LOCATION 'B': (penetrations were identified from the Nursing Home side)
Three unsealed penetrations (including a 5 inch diameter metal duct) were located above the ceiling to the Nursing Home Corridor that serves Patient Room 407. These are located several feet to the north of door to room 407.
Tag No.: K0067
Based on observations made during review of the logs, policies and procedures of the facility between the hours of 11:00 am and 3:00 pm, while accompanied by the Environmental Services Director, and a health care consultant's District Manager, the facility failed to provide documentation of how many filters are in each air handling unit, the level of filtration associated with each filter bank, and the CFM rating of the unit to failitate maintenance and future inspections/surveys.