HospitalInspections.org

Based on observation and interview, the facility failed to inspect and maintain the building construction type for a Type II (222)-rated building, affecting one of over two building roof sections.

Findings include:

Observation and interview on February 22, 2024, at 10:17 a.m., revealed the boiler room roofline had a section of rubber roofing material (measuring approximately 80 feet squared) used as a temporary fix. The material was laying over the existing roofline, and there were weights placed to secure it from movement. Additionally, the temporary material was tight against the boiler exhaust pipe without a rated thimble in place.

Through interview on a previous date, the boiler exhaust reached a temperature high enough that caused the roof material to fail/melt. The building management group was responsible for the roof repairs and had completed the temporary fix.

Observation on February 28, 2024, revealed the weights were removed and the rubber roofing material was secured in place. There was also a thimble in place around the section of boiler exhaust, but it was unknown at the time of the survey if the repair or material was approved/rated for this application. Further discussions indicated that the facility failed to obtain required approval from the Department of Health State Plan Review and receive a granted occupancy from the Life Safety Division for this project.

Interview with the director of plant operations and maintenance technician on February 28, 2024, at 10:17 a.m., confirmed the deficiencies.

Based on observation and interview, the facility failed to maintain doors with self-closing devices on one of six building levels.

Findings include:

Observation on February 22, 2024, between 9:30 a.m. and 9:34 a.m., revealed the following self-closure deficiencies:
A. (9:30 a.m.) Penthouse east door was damaged and would not close and latch in the frame. The facility provided an invoice that indicated that the door was in the process of being replaced;
B. (9:34 a.m.) Penthouse west door was damaged and would not close and latch in the frame. The facility provided an invoice that indicated that the door was in the process of being replaced;

Interview with the director of plant operations and maintenance technician on February 28, 2024, at 9:34 a.m., confirmed the door deficiencies.

Based on observation and interview, the facility failed to maintain two of more than twenty-five emergency exit signs.

Observation on February 22, 2024, between 9:38 a.m. and 11:30 a.m., revealed the following exit sign deficiencies:
A. (9:38 a.m.) Fourth floor elevator B lobby had a directional exit sign that lacked illumination;
B. (11:30 a.m.) First-floor corridor from the elevator lobby to the back of the building (north side) lacked an illuminated directional exit sign.

Interview with the maintenance technician on February 22, 2024, at 11:30 a.m., confirmed the exit sign deficiencies.

Based on observation and interview, the facility failed to maintain vertical openings in four of eight vertical shafts.
Findings include:
Observation on February 22, 2024, between 9:46 a.m. and 10:30 a.m., revealed the following vertical shaft doors failed to close and latch in the frame:
A. (9:46 a.m.) Fourth-floor shaft door, located next to the east nurses' station;
B. (9:57 a.m.) Fourth-floor west corridor had two vertical shaft doors that were adjusted to properly close and latch at the time of the survey;
C. (10:30 a.m.) Third floor shaft door, located between rooms 304 and 305.

Interview with the maintenance technician on February 22, 2024, at 10:30 a.m., confirmed the vertical door deficiencies.