HospitalInspections.org

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 5 of 5 residents.


Findings:

During the facility tour on 5/17/2018, between the hours of 9:00a-5:00p observation revealed unsealed penetrations in the boiler room. Observation also revealed the door to financial records storage was not self-closing.

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

Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was maintained in accordance with the requirements of NFPA 25. This deficiency has the potential to affect 5 of 5 residents.

Findings:

During the facility tour on 5/17/2018, between the hours of 9:00a-5:00p observation revealed painted sprinkler heads located in the kitchen and x-ray bathroom. Observation also revealed missing escutcheon located in x-ray.

Interview with Administrator revealed the facility was not aware that the automatic sprinkler system was maintained in accordance with the requirements of NFPA 25.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 5 of 5 residents.
4 of 4 quarters in 2017-2018 were deficient.

Findings:

During the record review on 5/17/2018, between the hours of 9:00a-5:00p record review revealed 4 of 12 fire drill were conducted for the last 12 months.

Interview with Administrator revealed the facility was not aware fire drills were not being held for all 3 shifts.

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.

Findings:

During the facility tour on on 5/17/2018, between the hours of 9:00a-5:00p observation revealed daisy chained power strips located in the nurses office powering IT devices. Observation also revealed an extension cord used for permenent wiring in the nurses office.

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

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 of residents.

Findings:

During the facility tour on on 5/17/2018, between the hours of 9:00a-5:00p observation revealed daisy chained power strips located in the rear office powering IT devices, an extension cord used for permenent wiring and missing cover plates over outlet boxes in the rear office. Observation also revealed emergency lights located at the rear exit and the front hall did not function properly when tested.

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