HospitalInspections.org

Based on observation and staff interview, the facility failed to maintain hazardous storage rooms per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.1.3 and 7.2.1.8.1. These deficient finding could have a patterned impact on the residents within the facility.

Findings include:

On 05/15/2024 between 9:00am and 1:00pm, it was revealed by observation that the area next to the transformer in the kitchen storage contained combustible materials. These materials must be removed, and no further storage item can be placed in this area marked with tape.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to maintain the fire alarm system per NFPA 101 (2012 edition), Life Safety Code, section 9.6.1.3, and NFPA 72 (2010 edition), National Fire Alarm and Signaling Code section 14.2.1.2.2. These deficient findings could have a patterned impact on the residents within the facility.

Findings include:

On 05/15/2024 between 9:00am and 1:00pm, it was revealed by a review of available documentation that the annual fire alarm inspection report dated 05/31/2023 that the facility provided at the time of the survey did not show that the sensitivity testing had been completed.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain spacing between storage and the sprinkler system per NFPA 101 (2012 edition), Life Safety Code, Section 9.7.5, NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 5.2.1.2, and NFPA 13 (2010 edition), Standard for the Installation of Sprinkler Systems, Sections 8.6.5.3.2 and 8.15.9. These deficient findings could a patterned impact on the residents within the facility.

Findings include:

On 05/15/2024 between 9:00am and 1:00pm, it was revealed by observation that storage materials had been placed on a storage rack, bringing the storage materials within the required 18 inch clearance area under the sprinkler heads. These obstructions were found in 330A Lab Area and Low level storage area.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain their smoke barrier per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.1, 19.3.7.3, 8.5.2.2, and 8.5.6.5. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 05/15/2024 between 9:00am and 1:00pm, it was revealed by observation that there was a penetration running from one smoke compartment to another above doors by Chapel door


An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to conduct fire drills under varied times and conditions per NFPA 101 (2012 edition), Life Safety Code, sections 19.7.1.6, 4.7.4, and 4.6.1.1. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 05/15/2024 between 9:00am and 1:00pm, it was revealed by a review of available documentation that fire drills did not meet the varying time requirement.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to conduct the electrical testing and maintenance per NFPA 99 Standards for Health Care Facilities 2012 edition, section 6.3.3.2, 6.3.4.1.3, and 6.3.4.2.1.2. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 05/15/2024 between 9:00am and 1:00pm, it was revealed by review of available documentation the required annual receptacle inspection documentation was not available at the time of the survey.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices per NFPA 99 (2012 edition), Health Care Facilities Code, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 70, (2011 edition), National Electrical Code, sections 400-8, and UL 1363. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 05/15/2024 between 9:00am and 1:00pm, it was revealed by observation that there were several electrical appliances plugged into a power strip in Director of Nursing Office.

An interview with the Director of Maintenance verified these deficient findings at the time of discovery.