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Based on observation and record review, the facility failed to obtain permit or approval before the modification of the gift shop in one (1) of one (1) observation.

The findings include:

During the facility tour on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, the inspector noticed the gift shop had received renovations to include the addition of a hand sink in the left corner of the room.

At the time of the observation, Employee #14 was queried about permits or approvals for the renovations completed. Employee #14 was unable to provide documentation of prior permit or approval for the repair or modification of the gift shop.

Based on observation, the facility failed to ensure that one (1) of two (2) exit signage was illuminated.


The findings include:

During the facility tour conducted on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, the exit sign in the Environmental Director's Office was observed not illuminated.

The failure to illuminate the exit sign creates a potential hazard for staff and patients exiting the facility in the event of an emergency.

A. Based on observation, the facility failed to ensure that four (4) of 40 ceiling tiles were present.

The findings include:

During the facility tour conducted on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, four (4) of 40 observations revealed missing ceiling tiles in the following areas:

1. Room across from B-1044
2. Room B103
3. "A" level storage room
4. Administration telephone closet

The missing ceiling tiles create a potential fire hazard for staff and patients, in the event of a fire emergency.

B. Based on observation, the facility failed to ensure that four (4) of six (6) lockers were wall mounted.

The findings include:

During the facility tour conducted on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, the facility lockers in the following areas were not wall mounted:

1. Room across from B-1044
2. Maintenance shop

The unmounted lockers pose a potential safety hazard for staff when exiting the facility, in the event of an emergency.

C. Based on observation, the facility failed to ensure that ceiling tiles are free from penetration in one (1) of 4 observations.

The findings include:

During the facility tour conducted on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, the facility's administration electrical closet had ceiling tile penetrations.

The ceiling tile penetrations create a potential fire hazard for staff and patients, in the event of a fire emergency.

1. Based on observations, it was determined the facility failed to ensure that all sprinkler heads were maintained in a manner to ensure proper operation in the event of an emergency in 14 of 200 sprinkler heads inspected as follows:

A. During observations made January 23, 2017, in the presence of Employee #14, eight (8) of 200 sprinkler head were observed corroded in the following areas:

1. "A" Level storage room- two (2) of two (2)
2. Quality Control office- two (2) of two (2)
3. Wash Area of Kitchen- four (4) of four (4)

The corroded sprinkler heads pose a potential fire hazard, in the event of an emergency.

B. During observations on January 23, 2017, at 11:17 AM, in the presence of Employee #14, three (3) of four (4) sprinkler heads and shaft surfaces were accumulated with dust, over the steam table in the Main Kitchen. Also, the sprinkler water supply lines were soiled with dust and other debris, over the steam tables in three (3) of four (4) observations.

The failure to properly maintain the sprinkler heads pose a potential fire hazard, in the event of an emergency.

2. During the tour of the rear hallway of the main Kitchen on January 23, 2017, at 11:20 AM, in the presence of Employee #14, three (3) of four (4) sprinkler heads, and shaft surfaces were observed covered with a dark residue.

The failure to properly maintain the sprinkler heads pose a potential fire hazard, in the event of an emergency.

3. Based on observation, the facility failed to ensure the standpipe cabinet hardware was not damaged one (1) of 4 observations.

The findings include:

During the facility tour conducted on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, the facility's standpipe cabinet hardware, in the dietitian corridor, was damaged.

The damaged standpipe cabinet poses a potential hazard, in the event of an emergency.

4. Based on observation, the facility failed to ensure the pump room was not being used for storage in one (1) of one (1) observation.

The findings include:

During the facility tour conducted on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, the facility's pump room was observed being used for storage.

The storage in the pump room creates a potential hazard, in the event of an emergency.






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Based on observations, it was determined that the facility staff failed to ensure the entrance door to the hallway corridor opened and closed freely, in one (1) of one (1) observation.

The findings include:

During the tour of 2 North on January 24, 2017, at approximately 1:45 PM, in the presence of Employee #14, the entrance door to room 2006, leading to the hallway, made contact with the floor making it difficult to open and close.

The failure of the entrance door to open and close freely poses a potential fire hazard, allowing the passage of smoke, in the event of a fire emergency.

Based on observation, it was determined the facility failed to ensure the wall surfaces were free of penetrations, in four (4) of six (6) observations.

The findings include:

During observations on January 23 through 26, 2017, at approximately 9:00 AM through 4:00 PM, in the presence of Employee #14, four (4) of six (6) observations revealed wall penetrations as follows:

1. A two-inch penetration was observed in wall surfaces in Room 2007, in one (1) of one (1) observation.

2. A 12" X 12" inch opening was observed in the lower wall of the women bathroom stall, in one (1) of three (3) observations.

3. Penetrations approximately one (1) inch in diameter were observed in wall surfaces around steam pipes in the rear of the flat skillet and steamer, in two (2) of two (2) observations.

The wall penetrations pose a potential fire hazard, in the event of a fire emergency.

1. Based on observations, it was determined the facility failed to ensure that all electrical outlets were covered, in one (1) of two (2) observations.

The findings include:

During observations on January 23 through 26, 2017, in the presence of Employee #14, two (2) of two (2) electrical outlet covers, in trash room, were missing.

The missing electrical covers create a potential hazard.

2. Based on observations, it was determined the facility failed to ensure that all doors are labeled, in one (1) of two (2) electrical closet observations.

The findings include:

During observations on January 23 through 26, 2017, in the presence of Employee #14, one (1) of two (2) electrical closets in the auditorium was not labeled.

The missing door label poses a potential hazard in the event of an emergency.

Based on record review, it was determined the facility failed to ensure all fire drills were completed.

The findings include:

During a record review conducted on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, revealed the fire drill reports lacked documentation of the method of egress.

The facility staff failed to ensure that the fire drill documentation included the method of egress.

Based on record review, it was determined the facility failed to retain a copy of the medical gas certification.

The record review conducted on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, revealed the facility medical gas certification for 2017 is missing.

The facility's records lack documented evidence of medical gas inspection and certification.

The findings were reviewed, discussed, and acknowledged by Employee #14 at the time of observation.

Based on observation, the facility load tests are missing.

The findings include:

The record review conducted on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, revealed the facility failed to complete the generator load test consistently. The Generator #5 load test results were missing for: January 2016, February 2016, September 2016, and November 2016.

The facility's records lacked documented evidence of all routine generator load tests.

The findings were reviewed, discussed, and acknowledged.