HospitalInspections.org

Based on visual observation the facility failed to provide the continuation of the exit discharge to include access to the public way from all required exits. The access provides an easier transition for occupants to evacuate from all exits in the building. The deficient practice had the potential to affect 19 of 19 residents.
The exit discharge was deficient for 5 exits.

Findings:

During the facility tour on 4/4-5/2018, between the hours of 8:00a-4:30p observation revealed exit discharge from the cross hall, exit by dining & exits from basement were not provided with hard packed all weather surface in accordance with CMS S & C letter 05-38.

Interview with Administrator revealed the facility was not aware that the exit discharge did not continue to the public way.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 19 of 19 residents.

Findings:

During the facility tour on 4/4-5/2018, between the hours of 8:00a-4:30p observation revealed:
-Door to HR storage > 50 square feet was not self-closing.
-Door to Central supply storage from the workout room not self-closing.
-Door to stairwell by nurses station did not latch in the frame.
-Main door to Central supply does not latch in the frame when door self closes.
-Door to infectious control does not latch in the frasme.
-Unsealed penetrations in the wall of the elevator room and Central supply storage.

Interview with Administrator revealed the facility was not aware of the walls of the hazardous areas having unsealed penetrations or the doors to the hazardous areas were required to self-close and latch in the frame.

Based on visual observation and record review the facility failed to assure that routine cleanings was conducted on the commercial hood/suppression system. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system. The deficient practice had the potential to affect 19 of 19 residents.

Findings:

During the facility tour on 4/4-5/2018 and record review, between the hours of 8:00a-4:30p observation revealed grease buildup on the fan of the kitchen hood system. Documentation revealed this system was last cleaned in 2015.

Interview with Administrator revealed the facility was not aware the hood system had not been cleaned.

Based on visual observation this non sprinklered facility failed to assure that the smoke compartmentation of the membrane between the egress corridor and rooms, adjacent to the egress corridor, were not compromised. Repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 19 of 19 residents.


Findings:

During the facility tour on 4/4-5/2018, between the hours of 8:00a-4:30p observation revealed penetrations in the corridor walls at Case Management office, Room 209 & basement corridor by rear exit of Central supply.

Interview with Administrator revealed the facility was not aware of the penetrations in the corridor walls that would allow the transfer of smoke from one room to another.

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. The deficient practice had the potential to affect 19 of 19 residents.

Findings:

During the facility tour on 4/4-5/2018, between the hours of 8:00a-4:30p observation revealed penetrations in the barrier wall by dining and the barrier wall of maintenance hall.

Interview with Administrator revealed the facility was not aware of unsealed penetration.

Based on visual observation, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70. Improper wiring creates a high risk of injury and/or death. The deficiency has the potential to affect 19 of 19 residents.

Findings:

During the facility tour on 4/4-5/2018, between the hours of 8:00a-4:30p observation revealed:
-Hydroculator located in therapy was not connected to a GFI outlet.
-The medicine refrigerator in infectious control was not connected to emergency power.
-Extension cord used for permanent wiring in the Lab.
-Unsecured electrical panels located on Lab hall, Surgery hall & Outpatient hall.
-Exposed wiring in the ceiling in kitchen.

Interview with Administrator revealed the facility was not aware of the electrial issues throughout the building.

Based on visual observation, the facility failed to comply with the requirements of NFPA 99 and other applicable codes with regard to electrical systems. In cases of a failure in the electrical systems this could have a detrimental affect on the life safety of the occupants. The deficient practice had the potential to affect 19 of 19 residents.

Findings:

During the facility tour on 4/4-5/2018, between the hours of 8:00a-4:30p observation revealed no emergency stop located remote of the generator serving the west wing.

Interview with Administrator revealed the facility was not aware that these electrical system components were not provided.