HospitalInspections.org

Based on document review and interview it was determined that the Emergency Preparedness Plan did not include a facility-based and community-based risk assessment.

Findings include:
Interview and documentation review on January 18, at 9:30 a.m., revealed the facility lacked an Emergency Preparedness Plan that included an updated facility-based and community-based risk assessment, utilizing an all-hazards approach.

Interview with the Director of Plant Operations Tech on Janaury 18 2022, at 9:30 a.m., confirmed the facility Emergency Preparedness Plan lacked an updated facility-based and community-based risk assessment.

Based on observation and interview, it was determined the facility failed to maintain a two-hour fire resistance rating to separate the health care occupancy from other occupancies, in one instance affecting the entire facility.

Findings include:

1. Observation on January 18, 2022, at 1:21 p.m., an above ceiling inspection at the doors seperating component four and occupational therapy had multiple unsealed wire penetrations.

Interview with the Facility Administrator and the Director of Plant Operations on January 19, 2022, at 1:30 p.m., confirmed the unsealed wire penetrations in the two-hour occupancy separation wall.

Based on observation and interview, it was determined the facility failed to maintain a two-hour fire resistance rating to separate the health care occupancy from other occupancies, in one instance affecting the entire facility.

Findings include:

1. Observation on January 18, 2022, at 1:21 p.m., revealed the two-hour wall in the rear of the old security office had multiple unsealed wire penetrations.

Interview with the Director of Plant Operations on January 19, 2022, at 1:30 p.m., confirmed the unsealed wire penetrations in the two-hour occupancy separation wall.

Based on observation and interview, it was determined the facility failed to provide the required number of exits in one instance, on one of three floors.

Findings include:

1. Observation on January 18, 2022, at 1:00 p.m., revealed the second means of egress on the second floor of Wing 2 ASU, is through a non-compliant building.

Interview with the Facility Administrator Director of Plant Operations on January 19, 2022, at 1:30 p.m., confirmed the 2nd floor lacked two approved exits.

Based on document review and interview, it was determined the facility failed to perform the required monthly exit sign inspection, affecting the entire facility.

Findings Include:

Document review on January 18, 2022 at 9:35 a.m., revealed the facility lacked documentation confirm if the monthly exit sign inspection have ever been performed.

Interview with the Facility Administrator and the Director of Plant Operations on January 19, 2022, at 1:30 p.m., confirmed the facility lacked documentation for exit sign inspection at the time of the survey.

Based on observation and interview, it was determined the facility failed to maintain the two hour fire rating of the emergency generator enclosure for one of two emergency generators, affecting the entire facility. Installation shall be accordance with NFPA 101, 8.2.3 and NFPA 110, 7.2.1.1

Findings include:

1. Observation on January 19, 2022, at 9:15 a.m., revealed the fire rating tag on the door to the emergency generator room was painted over and the facility is unable to confirm that the door maintains a two-hour fire resistive rating.

Interview with the Facility Administrator and the Director of Plant Operations on January 19, 2022, at 1:30 p.m., confirmed the facility can not provide documentation that the emergency generator room door, maintains a two-hour fire resistive rating.

Based on observation and interview, it was determined the facility failed to maintain the automatic fire alarm system in one instance, affecting the entire facility.

Findings include:

1. Observation on January 19, 2022, at 9:15 a.m., revealed the fire alarm system panel had an active trouble code and facility staff was unable to clear the code at the time of the survey.

Interview with the Facility Administrator and the Director of Plant Operations on January 19, 2022, at 1:30 p.m., confirmed the trouble code for the automatic fire alarm panel was present at the time of the inspection

Based on observation and interview, it was determined the facility failed to maintain the automatic fire alarm system in one instance, affecting the entire facility.

Findings include:

1. Observation on January 19, 2022, at 9:15 a.m., revealed the fire alarm system panel had an active trouble code and facility staff was unable to clear the code at the time of the survey.

Interview with the Facility Administrator and the Director of Plant Operations on January 19, 2022, at 1:30 p.m., confirmed the trouble code for the automatic fire alarm panel was present at the time of the inspection.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting the entire facility.

Findings include:

1. Observation on January 19, 2022 at 9:48 a.m., revealed the automatic sprinkler gauges in the first-floor sprinkler room on the Operating room suite were dated 2006 and the facility could not provide documentation that the gauge had been changed or recalibrated within the last five years.

Interview with the Facility Administrator and Director of Plant Operations on January 19, 2022, at 1:30 p.m., confirmed the automatic sprinkler system deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in six instances, affecting the entire facility.

Findings include:

1. Observation on January 18, 2022, revealed the following automatic sprinkler system deficiencies:

a) 11:22 a.m., there were multiple dirty sprinkler heads in physical therapy gym, located on the fifth floor; b) 11:24 a.m., there were multiple sprinkler heads missing escutcheons in the physical therapy gym, located on the fifth floor; c) 11:36 a.m., the facility failed to maintain a smoke/heat resistive ceiling for the proper activation/operation of the automatic sprinkler system. there were missing ceiling tiles in the pool chemical room, located on the fifth floor; d) 12:40 p.m., there was a sprinkler head missing an escutcheon in the closet near reception in suite 101 on the fourth floor; e) 12:45 p.m., there was a sprinkler head missing an escutcheon in the handicap rest room in suite 101 on the fourth floor; f) 12:48 p.m., there were two missing ceiling tiles in the closet near the exit door in suite 101 on the fourth floor.

Interview with the Facility Administrator and Director of Plant Operations on January 19, 2022, at 1:30 p.m., confirmed the automatic sprinkler system deficiencies.

2. Observation on January 19, 2022 at 10:00 a.m., revealed the automatic sprinkler gauges in the fourth-floor fire pump room were dated 2016 and the facility could not provide documentation that the gauge had been changed or recalibrated within the last five years.

Interview with the Facility Administrator and Director of Plant Operations on January 19, 2022, at 1:30 p.m., confirmed the automatic sprinkler system deficiencies.

Based on observation and interview, it was determined that the facility failed to maintain portable fire extinguishers in one instances, affecting component number four.

Findings include:

1. Observation on January 18, 2022, at 12:42 p.m., revealed access to a fire extinguisher was obstructed by miscellaneous storage in the suite 101 sink room, located on the fourth floor.

Interview with the Facility Administrator and the Director of Plant Operations on January 19, 2022, at 1:30 p.m., confirmed access to the fire extinguisher was obstructed by miscellaneous storage.

Based on observation and interview, it was determined the facility failed to maintain self closing smoke barrier doors, with a coordinating device in two instances, affecting component four. According to NFPA 80, 2010 Edition, 6.4.1.2 and 6.4.1.2.1.

Findings include:

1. Observation on January 18, 2022, revealed the following smoke barrier doors, with door coordinating devices, did not close in there frame when tested:

a) 11:21 a.m., the physical therapy side track doors, located on the fifth floor;
b) 11:43 a.m., the hospice side track doors, located on the fifth floor.

Interview with the Facility Administrator and the Director of Plant Operations on January 19, 2022, at 1:30 p.m., confirmed the above listed smoke barrier doors, with door coordinating devices, did not close in there frame when tested.

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles, affecting two of four smoke compartments.

Findings include:

1. Observation on Janaury 18, 2022, revealed the following electrical outlets, within six feet of a sink, were not GFCI protected:

a) 11:30 a.m., physical therapy room 1 on the fifth floor;
b) 11:32 a.m., physical therapy room 2 on the fifth floor;
c) 11:34 a.m., physical therapy room 3 on the fifth floor;
d) 11:36 a.m., physical therapy room 4 on the fifth floor;
e) 12:30 p.m., suite 103 exam room 1 on the fourth floor;
f) 12:32 p.m., suite 103 exam room 2 on the fourth floor;
g) 12:33 p.m., suite 103 exam room 3 on the fourth floor;
h) 12:35 p.m., suite 103 exam room 4 on the fourth floor;

2. Observation on Janaury 18, 2022, at 11:52 a.m., revealed there was a damaged electrical receptacle in the hall way across from the door to hospice laundry room, on the fifth floor.


Interview with Facility Administrator and Director of Plant Operations on January 19, 2022, at 1:30 p.m., confirmed the electrical receptacle deficiencies.

Based on documentation review and interview, it was determined that the facility failed to maintain hospital grade electrical receptacles in patient sleeping areas and in areas where deep sedation or general anesthesia is administered, affecting the entire facility.

Findings include:

1. Documentation review on November 12, 2020, at 9:40 a.m., revealed the facility lacked documentation for an annual integrity testing of hospital grade electrical receptacles in the patient sleeping rooms and in areas where deep sedation or general anesthesia is administered.


Interview with Facility Administrator and the Director of Plant Operations on January 19, 2022, at 1:30 p.m., confirmed the facility lacked documentation for an annual integrity test of hospital grade electrical receptacles in patient sleeping areas and in areas where deep sedation or general anesthesia is administered, performed within the last 12 months.

Based on documentation review and interview, it was determined the facility failed to maintain two of two emergency generators, affecting the entire facility. Maintenance shall be in accordance with NFPA 110, 8.3.8

Findings include:
1. Observation on January 18, 2022, at 9:50 a.m., revealed the facility failed to perform the required annual fuel quality test, for two emergency generators.

2.Review of documentation on January 18, 2022, at 9:55 a.m., revealed the facility lacked documentation to confirm the monthly testing/function of the automatic transfer switch for two automatic transfer switches.

Interview with Facility Administrator and Director of Plant Operations on January 19, 2022, at 1:30 p.m., confirmed the facility lacked documentation for the annual fuel quality testing and the monthly testing/function of the automatic transfer switches.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in one instance, affecting one of four smoke compartments.
Findings include:
1. Observation on January 18, 2022, at 11:45 a.m., revealed there was a microwave, connected to a power strip in the staff lounge on the fifth floor.
Interview with the Facility Administrator and Director of Plant Operations on January 19, 2022, at 1:30 p.m., confirmed the misuse of electrical wiring.