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2555 JIMMY JOHNSON BLVD

PORT ARTHUR, TX 77640

General Requirements - Other

Tag No.: K0100

Based on an observation made of the facility during the walk through of both facilities, facility A ( Port Arthur) and facility B ( Beaumont) location, it was observed and noted that the hospital has turned several licensed rooms with beds into storage rooms, offices, and break rooms. This occurrence was noted a total of 16 times for both facilities, facility A and facility B. The process to delicense a bed in Texas requires a application with the office of ARU and any room that has patient services, medical gases, and a nurse call system must be removed. If patient bed in a room is licensed that room must function at all times for what ever the bed license says on file with the state and ARU.

Multiple Occupancies

Tag No.: K0131

A note of record from the survey during the dates of 4/18/2022 through 04/21/2022 it was observed and noted that at facility B (Beaumont) , only the first floor is licensed with patient beds. The 2nd floor of the facility is a non licensed clinic, that does have a second entrance too.

Emergency Lighting

Tag No.: K0291

Based on a observation made of facility A ( Port Arthur) it was observed and noted that several exit lights are not lit up or illuminating as required. This was noted during the walk through from 4/18/2022 through 04/21/2022.

Fire Alarm System - Notification

Tag No.: K0343

Based on an observation made of the paperwork provided during the survey from 04/18/2022 through 04/21/2022 it was observed and noted that no fire alarm devices were tested in the facility during the 1st 3rd and 4th quarters of 2020.

Fire Alarm System - Testing and Maintenance

Tag No.: K0345

Based on a visual inspection of facility B ( Beaumont) it was noted and observed on 04/21/2022 that the fire alarm panel does not have any quarterly blue inspection tags on the fire alarm panel for 2019,2020,2021 and 2022.

Sprinkler System - Installation

Tag No.: K0351

Based on a visual inspection of facility B (Beaumont) on 04/21/2022 it was observed that all the fire sprinkler heads at the loading dock are corroded and need replacing.

Building Services - Other

Tag No.: K0500

Based on an observation made of facility A ( Port Arthur) it was observed during testing that the negative pressure was not working in the patient restroom in room 514.

HVAC

Tag No.: K0521

Based on an observation made of facility A (Port Arthur) it was observed during the walk through that the HVAC filters for AHU # 13 filters were dirty and needed to be replaced.

Operating Features - Other

Tag No.: K0700

Based on an observations made during the survey of facility A (Port Arthur) during the dates of 04/1/8/2022 through 04/21/2022, it was observed and noted that none of the patient curtains in the LDRP have the NFPA-701 flame retardant tag on them.

Fire Drills

Tag No.: K0712

Based on an observation made of the paperwork provided for facility a (Port Arthur) it was noted that the facility is performing "silent fire drills" the term silent fire drill does not exist with the state of Texas and the ARU unit,

Electrical Systems - Essential Electric Syste

Tag No.: K0918

Based on an observation made of the paperwork provided during the survey of facility A, ( Port Arthur) it was noted that were several weeks of the weekly generator logs missing from the paperwork files. A total of 5 weeks were missing for weekly generator inspections during the years 2020 and 2021.