HospitalInspections.org

Based on observation and staff interview, the facility failed to maintain hazardous storage rooms per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.1.3 and 7.2.1.8.1. These deficient finding could have a patterned impact on the residents within the facility.

Findings include:

On 06/25/2024 between 10:00am and 2:00pm, it was revealed by observation that storage room / office areas that require self closers did not have a self-closing device in the following areas:

1) ER142 Room
2) ER144 Room
3) W118 Room
4) Decontamination storage room
5) CL141B Lab Door


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

Based on observation, a review of available documentation, and staff interview, the facility failed to install the required safety features for cooking equipment per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.5.3 (9) and 19.3.2.5.4. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 06/25/2024 between 10:00am and 2:00pm, it was revealed by observation that the residential stove located in physical therapy was not equipped with a lock-out switch and was not on a timer, not exceeding a 120-minute capacity, that automatically deactivates the cook-top or range, independent of staff action.

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

Based on observation and staff interview, the facility failed to maintain spacing between storage and the sprinkler system per NFPA 101 (2012 edition), Life Safety Code, Section 9.7.5, NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 5.2.1.2, and NFPA 13 (2010 edition), Standard for the Installation of Sprinkler Systems, Sections 8.6.5.3.2 and 8.15.9. These deficient findings could a patterned impact on the residents within the facility.

Findings include:

On 06/25/2024 between 10:00am and 2:00pm, it was revealed by observation that storage materials had been placed on a storage rack, bringing the storage materials within the required 18 inch clearance area under the sprinkler heads. These obstructions were found in:

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

Based on observation and staff interview, the facility failed to maintain their smoke barrier per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.1, 19.3.7.3, 8.5.2.2, and 8.5.6.5. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 06/25/2024 between 10:00am and 2:00pm, it was revealed by observation that there was a penetration running from one smoke compartment to another on the Lower Level mechanical room.

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

Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices per NFPA 99 (2012 edition), Health Care Facilities Code, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 70, (2011 edition), National Electrical Code, sections 400-8, and UL 1363. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 06/25/2024 between 10:00am and 2:00pm, it was revealed by observation that there were several electrical appliances plugged into a power strip in the following areas:

1) Maintenance room L011
2) Scheduling Office in surgery area

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