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CCM HEALTH
Hazardous Areas - Enclosure
Tag No.: K0321
Based on observation and staff interview, the facility failed to maintain hazardous area enclosures per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.1, 19.3.2.1.3, and 19.3.6.3.5. These deficient findings could have a patterned impact on the residents within the facility.
Findings include:
1. On 12/10/2024 between 9:00 AM and 12:30 PM, it was revealed by observation that the Oncology Clean Linen Room was being used to store combustible items and did not have a self-closing device on the door.
2. On 12/10/2024 between 9:00 AM and 12:30 PM, it was revealed by observation that Patient Room 112 was being used to store combustible items and did not have a self-closing device on the door.
An interview with the Maintenance Manager verified these deficient findings at the time of discovery.
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, section 5.4.1.4.2. This deficient finding could have a widespread impact on the residents within the facility.
Findings include:
On 12/10/2024 between 9:00 AM and 12:30 PM, it was revealed by observation that several sprinkler heads were being stored unsecured in the basement sprinkler riser room cabinet.
An interview with the Maintenance Manager verified this deficient finding at the time of discovery.
Fire Drills
Tag No.: K0712
Based on a review of available documentation and staff interview, the facility failed to conduct fire drills per NFPA 101 (2012 edition), Life Safety Code section 19.7.1.6. This deficient finding could have a widespread impact on the residents within the facility.
Findings include:
On 12/10/2024 between 9:00 AM and 12:30 PM, it was revealed by a review of available documentation that the fire drills for the 3rd shift were taking place between 0600 and 0609 hours during each quarterly drill and times were not being varied from drill to drill.
An interview with the Maintenance Manager verified this deficient finding at the time of discovery.
Fundamentals - Building System Categories
Tag No.: K0901
Based on a review of available documentation and staff interview, the facility failed to provide a Risk Assessment per NFPA 99 (2012 edition), Health Care Facilities Code, section 4.2. This deficient finding could have a widespread impact on the residents within the facility.
Findings include:
On 12/10/2024 between 9:00 AM and 12:30 PM, it was revealed by a review of available documentation that the facility could not provide an NFPA 99 Risk Assessment for Chapters 5, 6, 9, 10 and 11 at the time of the survey.
An interview with the Maintenance Manager verified this deficient finding at the time of discovery.