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ESSENTIA HEALTH SANDSTONE
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on observation, a review of available documentation, and staff interview, the facility failed to inspect and maintain the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, sections 5.1.1.2, and 5.3.2.1. This deficient finding could have a widespread impact on the residents within the facility.
Findings include:
On 07/09/2025 at 2:13pm, it was revealed by a review of available documentation the facility failed to perform the five (5) year sprinkler system testing.
An interview with the Director of Maintenance verified these deficient findings at the time of discovery.
Smoking Regulations
Tag No.: K0741
Based on observation and staff interview, the facility failed to implement a staff smoking policy per NFPA 101 (2012 edition), Life Safety Code section 19.7.4. These deficient findings could have an isolated impact on the residents within the facility.
Findings include:
On 07/09/2025 at 1:47pm, it was revealed by observation that the facility could not provide a smoking policy that had been reviewed. As observed by surveyor the facility policy states that the policy must be reviewed every tree (3) years, the policy has not been reviewed since 01/23/2018.
An interview with the Director of Maintenance verified these deficient findings at the time of discovery.
Fundamentals - Building System Categories
Tag No.: K0901
Based on a review of available documentation and staff interview, the facility has failed to provide a complete facility Risk Assessment per NFPA 99 (2012 edition), Health Care Facilities Code, section 4.1. This deficient finding could have an isolated impact on the residents within the facility.
Findings include:
On 07/09/2025 at 1:40pm, it was revealed during documentation review and an interview with the Environmental Services that a complete utility risk assessment document could not be provided at the time of the survey. The document provided was missing date of completion and any reference on review time frames.
An interview with the Director of Maintenance verified these deficient findings at the time of discovery.
Electrical Equipment - Power Cords and Extens
Tag No.: K0920
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 a patterned impact on the residents within the facility.
Findings include:
On 07/09/2025 at 3:34pm, it was revealed by observation that there were electrical appliances plugged power-strips, multi-plug adapters and/or extension cords in the following areas;
1) Power-strip in Call Room (coffee maker is 1503)
2) Power-strip in room 1312 (coffee maker)
An interview with the Director of Maintenance verified these deficient findings at the time of discovery.