HospitalInspections.org

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Based on observation, the facility failed to maintain the 2-hour separation between construction types per the requirements of:

2012 NFPA 101, 19.1.3.5, and 8.2.1.3

This deficiency affects 1 of 2 smoke compartments.

Findings include:

On 03/01/2023, during a tour of the facility from 8:00 am to 3:30 pm, the surveyor observed an unsealed penetration of multiple orange cables on the South side (Building 2's side) of the 2-hour fire barrier between Building 1 and Building 2.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the means of egress per the requirements of:

2012 NFPA 101, 19.2.1, 7.2.1.5.1, and 7.2.1.5.3

This deficiency affects 1 of 2 smoke compartments.

Findings include:

On 03/01/2023, during a tour of the facility from 8:00 am to 3:30 pm, the surveyor observed a padlock and hasp on the outside Biohazard Storage Room door (outside the Laundry area).

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to provide documentation on the monthly testing of emergency lighting per the requirements of:

2012 NFPA 101, 19.2.9.1, and 7.9.2.3

This deficiency affects the only CT trailer at the facility.

Findings include:

On 03/01/2023, during a tour of the facility from 8:00 am to 3:30 pm, when the surveyor tested the emergency light located in the CT Trailer, it failed to illuminate.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and review of documentation, the facility failed to maintain continuous illumination of the exit signage per the requirements of:

2012 NFPA 101, 19.2.10.1, 7.10.5.2.1, and 7.10.9.1

This deficiency affects 2 of 2 smoke compartments and the CT trailer at the facility.

Findings include:

On 02/28/2023, during a tour of the facility from 12:30 pm to 4:00 pm, the surveyor observed the following:
1. The exit sign in the CT trailer was not illuminated
2. The facility failed to provide documentation of visually inspecting the exit signs for the last 12 months

A member of the maintenance staff was present when the deficiency was identified.

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Based on review of documentation, the facility failed to maintain continuous illumination of the exit signage per the requirements of:

2012 NFPA 101, 19.2.10.1, and 7.10.9.1

This deficiency affects 2 of 2 smoke compartments.

Findings include:

On 02/28/2023, during a tour of the facility from 12:30 pm to 4:00 pm, the surveyor observed the facility failed to provide documentation of visually inspecting the exit signs for the last 12 months

A member of the maintenance staff was present when the deficiency was identified.

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Based on review of documentation, the facility failed to maintain the fire alarm system per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, 14.4.5, Table 14.4.5, and 14.4.5.3.2

This deficiency affects 2 of 2 smoke compartments.

Findings include:

On 03/01/2023, during a tour of the facility from 8:00 am to 3:30 pm, the facility failed to provide the following documentation:
1. That an annual fire alarm inspection was conducted within the past 12 months. The last documented inspection report was dated 11/18/2021.
2. A smoke detector sensitivity test report completed within the past two years. The last documented sensitivity test was dated 02/04/2016.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the fire alarm system per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, 14.4.5, Table 14.4.5, and 14.4.5.3.2

This deficiency affects 2 of 2 smoke compartments.

Findings include:

On 03/01/2023, during a tour of the facility from 8:00 am to 3:30 pm, the facility failed to provide the following:
1. Documentation that an annual fire alarm inspection was conducted within the past 12 months. The last documented inspection report was dated 11/18/2021.
2. A smoke detector sensitivity test report completed within the past two years. The last documented sensitivity test was dated 02/04/2016.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.3.5.4, and 9.7.1.1 (1)
2010 NFPA 13, 6.2.7.1, 6.2.7.2, 7.6.1.5, and TIA 10-2

This deficiency affects 1 of 2 smoke compartments.

Findings include:

On 02/28/2023, during a tour of the facility from 12:30 pm to 4:00 pm, the surveyor observed the following:
1. The automatic sprinkler in the Drink/Snack Machine Room was missing its escutcheon plate leaving a ½" gap between the sprinkler head and the ceiling tile
2. The Laundry Area's automatic sprinkler anti-freeze system:
A. The placard on the anti-freeze loop was missing and therefor did not provide the following information:
a. Manufacture type and brand of anti-freeze
b. Concentration by volume of anti-freeze used
c. Volume of anti-freeze used in the system
B. The facility failed to provide a certificate from the anti-freeze manufacturer on wether the pre-mixed solution had been updated by September 30, 2022. The certificate shall include the following information:
a. Type of anti-freeze
b. Concentration by volume of the anti-freeze
c. The freezing point of the anti-freeze

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and review of documentation, the facility failed to maintain the automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.5, 9.7.7, and 9.7.8
2011 NFPA 25, Table 5.1.1.2, 5.2.4.1, and 5.3.2.1

This deficiency affects 2 of 2 smoke compartments.

Findings include:

On 03/01/2023, during a tour of the facility from 8:00 am to 3:30 pm, the facility failed to provide the following documentation:
1. Three of the four quarterly automatic sprinkler inspection records for the past 12 months. Only one report dated 12/05/2022 was provided.
2. Monthly inspection of the wet pipe sprinkler gauges
3. The automatic sprinkler system riser gauges had been calibrated or replaced within the past 5 years. The gauges were installed in February of 2016.

A member of the maintenance staff and the administrator were present when this deficiency was identified.

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Based on observation, the facility failed to maintain corridor doors per the requirements of:

2012 NFPA 101, 19.3.6.3.10, and 19.3.6.3.5
42 CFR 482.41 (b) (1) (ii)
S&C-07-18

This deficiency affects 1 of 2 smoke compartments.

Findings include:

On 03/01/2023, during a tour of the facility from 8:00 am to 3:30 pm, the surveyor observed the three Nurses Station store-front type corridor doors that only had dead-bolt style latches.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain corridor doors per the requirements of:

2012 NFPA 101, 19.3.6.3.10, and 19.3.6.3.5
42 CFR 482.41 (b) (1) (ii)
S&C-07-18

This deficiency affects 2 of 2 smoke compartments.

Findings include:

On 03/01/2023, during a tour of the facility from 8:00 am to 3:30 pm, the surveyor observed the following:
1. The two Emergency Department Waiting Room single store-front type corridor doors:
a. Were impeded from closing by kick down door stops
b. Only had dead bolt-style latches
2. The Environmental Services Manager's Office corridor door:
a. Was impeded from closing by dragging on the floor
b. When closed, did not close against the door stop and did not latch due to warping
c. The edges of the door were damaged by carts that if closed and latched would leave a 1-inch gap between the door and door frame

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, and 8.5.6.3

This deficiency affects 2 of 2 smoke compartments.

Findings include:

On 02/28/2023, during a tour of the facility from 12:30 pm to 4:00 pm, the surveyor observed unsealed penetrations of a 2" PVC conduit and multiple gray cables above the ceiling on both sides of the smoke barrier near Office 203.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, and 8.5.6.3

This deficiency affects 2 of 2 smoke compartments.

Findings include:

On 02/28/2023, during a tour of the facility from 12:30 pm to 4:00 pm, the surveyor observed unsealed penetrations of a ½ inch EMT conduit and multiple blue cables above the ceiling on both sides of the smoke barrier between the Pharmacy and the CNO's Office.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the electrical equipment per the requirements of:

2012 NFPA 101, 19.5.1.1, and 9.1.2
2012 NFPA 70, 408.7

This deficiency affects 1 of 2 smoke compartments.

Findings include:

On 02/28/2023 during a tour of the facility from 12:30 pm to 4:00 pm, the surveyor observed one unused opening for a circuit breaker in three separate electrical panels in the basement Boiler Room. One panel was labeled as New Basement SWBD, the other two panels were not labeled.

A member of the maintenance staff and the administrator were present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the smoke dampers per the requirements of:

2012 NFPA 101, 19.5.2.1, and 9.2.1
2012 NFPA 90A, 5.4.8.2
2010 NFPA 105, 6.5.2

This deficiency affects 2 of 2 smoke compartments.

Findings include:

On 02/28/2023, during a tour of the facility from 12:30 pm to 4:00 pm, the facility failed to provide documentation of testing the smoke dampers within the past 6 years.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the designated smoking area per the requirements of:

2012 NFPA 101, 19.7.4 (5), and (6)

This deficiency affects 1 of 1 smoking areas.

Findings include:

On 02/28/2023, during a tour of the facility from 12:30 pm to 4:00 pm, the facility failed to provide the following in the designated smoking area:
1. A metal container with self-closing cover device
2. A noncombustible ashtray

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the receptacles not listed as hospital-grade at the residents' bed locations per the requirements of:

2012 NFPA 99, 6.3.4.1.3, and 6.3.3.2

This deficiency affects 2 of 2 smoke compartments.

Findings include:

On 03/01/2023, during a tour of the facility from 8:00 am to 4:00 pm, the facility failed to provide documentation of testing the receptacles not listed as hospital-grade at the patients' bed locations within the past 12 months.

A member of maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to maintain the emergency generator's remote annunciator per the requirements of:

2012 NFPA 99, 6.4.1.1.17

This deficiency affects 2 of 2 smoke compartents.

Findings include:

On 03/01/2023, during a tour of the facility from 8:00 am to 4:00 pm, the surveyor observed the diesel, Caterpillar 300 kW generator's remote annunciator failed to indicate any lights or alarms. The maintenance staff stated the old remote annunciator was to be replaced. The facility has the new remote annunciator on site, but it had not been installed.

A member of the maintenance staff was present when this deficiency was identified.

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45258

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Based on review of documentation and observation, the facility failed maintain the generator per the requirements of:

2012 NFPA 101, 19.2.9.1, and 7.9.2.4
2010 NFPA 110, 5.6.5.6, 5.6.5.6.1, 8.4.2.4, 1.3, 8.4.2, 8.4.2.3, and 8.3.8
2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, 6.5.1, and 6.5.4.2

This deficiency affects 2 of 2 smoke compartments.

Findings include:

On 03/01/2023, during a tour of the facility from 8:00 am to 4:00 pm, the facility failed to provide the following:
1. A labeled, remote manual stop station for the 2006 emergency generator. A labeled manual stop station was located within the weatherproof enclosure on the control panel; it was not remote. This was required when this generator was installed, see 1999 NFPA 110, 3-5.5.6.
2. Test the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature OR under operating temperature conditions at not less than 30% of the nameplate kW rating OR provide an annual 1.5 hour supplemental load test at not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less 75% of the EPS nameplate KW rating for one continuous hour for a total test duration of not less than 1.5 continuous hours.
3. Documentation that a fuel quality test was performed within the past twelve months using tests approved by ASTM standards

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation and observation, the facility failed maintain the generator per the requirements of:

2012 NFPA 101, 19.2.9.1, and 7.9.2.4
2010 NFPA 110, 5.6.5.6, 5.6.5.6.1, 8.4.2.4, 1.3, 8.4.2, 8.4.2.3, and 8.3.8
2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, 6.5.1, and 6.5.4.2

This deficiency affects 2 of 2 smoke compartments.

Findings include:

On 03/01/2023, during a tour of the facility from 8:00 am to 4:00 pm, the facility failed to provide the following:
1. A labeled, remote manual stop station for the 2006 emergency generator. A labeled manual stop station was located within the weatherproof enclosure on the control panel; it was not remote. This was required when this generator was installed, see 1999 NFPA 110, 3-5.5.6.
2. Test the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature OR under operating temperature conditions at not less than 30% of the nameplate kW rating OR provide an annual 1.5 hour supplemental load test at not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less 75% of the EPS nameplate KW rating for one continuous hour for a total test duration of not less than 1.5 continuous hours.
3. Documentation that a fuel quality test was performed within the past twelve months using tests approved by ASTM standards

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain electrical equipment per the requirements of:

2012 NFPA 101, 19.5.1.1, and 9.1.2
2012 NFPA 70, 400.7 (B)
CMS S&C: 14-46-LSC

This deficiency affects 1 of 2 smoke compartments.

Findings include:

On 02/28/2023 during a tour of the facility from 12:30 pm to 4:00 pm, the surveyor observed a microwave and a refrigerator were plugged into a power strip, that was plugged into an extension cord in the Pharmacy.

A member of the maintenance staff and the administrator were present when this deficiency was identified.

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Based on observation, the facility failed to maintain electrical equipment per the requirements of:

2012 NFPA 101, 19.5.1.1, and 9.1.2
2012 NFPA 70, 400.7 (B)

This deficiency affects 1 of 2 smoke compartments.

Findings include:

On 02/28/2023 during a tour of the facility from 12:30 pm to 4:00 pm, the surveyor observed a portable air conditioning unit was plugged into an extension cord that traveled 23 feet across the room to a wall outlet in the Central Supply Office (located on the 300 Hall).

A member of the maintenance staff and the administrator were present when this deficiency was identified.

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Based on observation, the facility failed to maintain an oxygen cylinder per the requirements of:

2012 NFPA 99, 11.6.2.3 (11)

This deficiency affects 1 of 2 smoke compartments.

Findings include:

On 02/28/2023, during a tour of the facility from 12:30 pm to 4:00 pm, the surveyor observed a Type "H", 150 cu. ft. unsecured oxygen cylinder in the Emergency Department Oxygen Storage Room.

A member of the maintenance staff was present when this deficiency was identified.