HospitalInspections.org

Based on observation and staff interview, the facility failed to maintain an egress corridors per NFPA 101 (2012 edition), Life Safety Code, section 7.1.10.1. These deficient findings could have a patterened impact on the residents within the facility.

Findings include:

1. On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by observation that a wheeled patient bed was being stored in front of an egress door in the radiology area.

2. On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by observation that a housekeeping cart was being stored in the lower level south stairwell.

An interview with the Maintenance Director verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.5.1, 19.3.5.4, and 9.7.1.1, and NFPA 13 (2010 edition), Standard for the Installation of Sprinkler Systems, sections 8.6.6.1, and 9.1.1.7. These deficient findings could have an isolated impact on the residents within the facility.

Findings include:

1. On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by observation that items being stored in the walk-in cooler in the kitchen area within 18 inches of the sprinkler head.

2. On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by observation there were several different types of wires zip tied and in contact with the fire sprinkler piping and hangers in the large basement storage room and the IT closet in the same area.

An interview with the Maintenance Director verified these deficient findings at the time of discovery.

Based on observation, review of available documentation, and staff interview, the facility failed to inspect and maintain the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, sections 9.7.5, and 9.7.7, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, section 5.1.1.2, and 5.4.1. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

1. On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by observation and review of available documentation and staff interview that the facility was overdue to have the annual inspection of sprinkler system. The last annual inspection was conducted on 01/10/2023.

2. On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by observation that several spare sprinkler heads were not securely stored within the fire sprinkler head cabinets in the south and north riser rooms.

An interview with the Maintenance Director verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to conduct fire drills under varied times and conditions per NFPA 101 (2012 edition), Life Safety Code, sections 19.7.1.6, and 4.7.4. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

1. On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by a review of available documentation that the facility was not varying the times of the fire drills throughout the year on each shift.

2. On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by a review of available documentation that the facility did not conduct a fire drill during the 2nd quarter of 2023 for the second shift.

An interview with the Maintenance Director verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to provide a Risk Assessment per NFPA 99 (2012 edition), Health Care Facilities Code, section 4.2. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 03/06/2024 between 09:00 AM and 1:15 PM, it was revealed by a review of available documentation that the NFPA 99 Risk Assessment had not been completed for this facility.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to provide documentation showing electrical receptacle testing and maintenance per NFPA 99 Standards for Health Care Facilities 2012 edition, sections 6.3.4.1.1, and 6.3.4.2. This deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 03/06/2024 between 9:00 AM and 1:15 PM, it was revealed by review of available documentation that the required hospital-grade receptacle testing and inspection documentation was not available at the time of the survey.

An interview with the Maintenance Director verified these deficient findings at the time of discovery.