HospitalInspections.org

Based upon record review and staff interviews on 02/04/2020 between approximately 0900 to 1400 hours the facility has failed to conduct testing/maintenance of the hood and duct fire suppression equipment protecting the commercial cooking equipment. This could result in the failure of the system to operate properly which would endanger the residents, staff and/or visitors within the facility.

The findings include:

The facility failed to provide documentation for a heat survey on their kitchen hood to verify the rating of the fusible links installed. Currently they have 450 degree links.
NFPA 17A 2009 5.6.1.5 At least one fusible link or heat detector shall be installed within each exhaust duct opening in accordance with the manufacturer ' s listing.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/04/2020 between approximately 0630 to 1600 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

The facility has a bent sprinkler deflector in A-W-037 soiled holding room. (Corrected at time of inspection.)
The facility has 3 sprinkler heads in the kitchen walk-in cooler that are missing fluid coloring.
NFPA 25, 2011 5.2.1.1.5 Glass bulb sprinklers shall be replaced if the bulbs have emptied.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/04/2020 between approximately 0600 to 1630 hours the facility has failed to maintain corridors construction as capable of resisting smoke. This could result in toxic products of combustion getting into the room or into the exit corridor in the event of a fire which would endanger the patients, staff and/or visitors within the smoke compartment.

The findings include:

The facility has penetrations in the following locations:
1. CUP 23B above door. (Corrected at time of inspection.)
2. Ceiling tile adjacent to the Stryker Storage room. (Corrected at time of inspection.)
3. Above door A-W-022. (Corrected at time of inspection.)

Bonnie Lake ED:
1. 6x12 penetration in MDF Room

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/04/2020 between approximately 0600 to 1630 hours the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.

The findings include:

The facility has fire doors that will not close and latch in the following locations:
1. A-W-037. (Corrected at time of inspection.)
2. M391. (Corrected at time of inspection.)
3. M350. (Corrected at time of inspection.)
4. 1-C002 and 1-C-002.1. (Corrected at time of inspection.)

Bonnie Lake ED:
1. Cross corridor fire door adjacent Exam Room 3. (Corrected at time of inspection.)

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/04/2020 between approximately 0900 to 1330 hours the facility failed to properly maintain all building service equipment. Failure to maintain building service equipment exposes emergency personnel to not be able to use the equipment if required during an emergency.

The findings include:

Facility failed to conduct monthly elevator firefighter recall testing as required. Facility provided 10 of 12 monthly firefighter recall test reports. Facility states that they recently learned that the requirement is monthly and are now conducting them as required.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on 02/04/2020 between approximately 0600 to 1630 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger patients, staff, and visitors in the facility due to the increased fire risk.

The findings include:

The facility has a power strip plugged into another power strip in the Main Electrician's Office. (Corrected at time of inspection.)

The facility has a Keurig plugged into a power strip in the Speech Resource Office. (Corrected at time of inspection.)

The facility has two power strips plugged into a multi plug adapter in 2-W-82. (Corrected at time of inspection)

The facility failed to restrict the use of extension cords in the following locations:
1. Room 1-W-172. (Corrected at time of inspection.)
2. IT space in CUP Control Room. (Corrected at time of inspection.)
3. 2-E-103. (Corrected at time of inspection.)
4. 2-E-096. (Corrected at time of inspection.)

The above was discussed and acknowledged by the facility staff.