HospitalInspections.org

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Based on review of documentation and interview, the facility failed to provide documentation on the monthly testing of emergency lighting per requirements of:

2012 NFPA 101, 19.2.9.1, and 7.9.3.1.1 (1)

This deficiency could affect all occupants.

On 06/26/2019, during a tour of the facility from 2:00 pm to 3:30 pm, the facility failed to provide documentation on the monthly testing of the emergency lighting.

A member of the maintenance staff was present when the deficiency was found.
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Based on review of documentation and interview, the facility failed to provide documentation of the monthly inspections of the exit signage per requirements of:

2012 NFPA 101, 19.2.10.1, and 7.10.9.1

The deficiency could affect all occupants.

On 06/26/2019, during a tour of the facility from 2:00 pm to 3:30 pm, the facility failed to provide documentation of the monthly inspections and visual checks on all exit signage.

A member of the maintenance staff was present when the deficiency was found.
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Based on observation, review of documentation and interview, the facility failed to maintain the automatic sprinklers per requirements of:

2012 NFPA 101, 9.7.5
2011 NFPA 25, 5.3.1.1.1.6, and 5.3.1.1.1.3

Findings include:

On 06/26/2019, during a tour of the facility from 2:00 pm to 3:30 pm, the facility failed to provide documentation on the following:
1. The 2006 dry sprinklers installed in the kitchen walk-in cooler and freezer had been replaced or a representative sample tested within 10 years of installation.
2. The 1994 sprinklers installed in the East Wing of the 1966 Bldg. and in the 1994 Addition had been replaced or a representative sample tested within 20 years of installation.
3. The 1996 sprinklers installed in the 1995 Addition (Emergency Room) had been replaced or a representative sample tested within 20 years of installation.

A member of the maintenance staff and administrator was present, when this deficiency was identified.

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Based on observation and interview, the facility failed to maintain the corridor doors per the requirements of:

2012 NFPA 101, 19.3.6.3.5
42 CFR 482.41 (b) (1) (ii)

Findings include:

On 06/26/2019, during a tour of the facility from 2:00 pm to 3:30 pm, the surveyor observed the corridor doors for rooms 110, 112, 114 and 116 failed to close completely and positive latch in the frame.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, and 8.5.6.2

Findings include:

On 06/26/2019, during a tour of the facility from 2:00 pm to 3:30 pm, the surveyor observed an approximately 3" x 12" opening above the ceiling in the smoke barrier over the door between the ER and North Wing.

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation and interview, the facility failed to maintain the dampers (smoke/fire/ceiling) per the requirements of:

2012 NFPA 101, 19.5.2.1, and 9.2.1
2010 NFPA 80, 19.4, and 19.5
2010 NFPA 90A, 5.4.8.1, and 5.4.8.2
2010 NFPA 80, 19.4.1.1
2010 NFPA 105, 6.5.2

This deficiency could affect all occupants.

Findings include:

On 06/26/2019, during a tour of the facility from 2:00 pm to 3:30 pm, the facility failed to provide documentation of testing the dampers (smoke/fire/ceiling) within the past 6 years.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to maintain the patient care-related electrical equipment (PCREE) per the requirements of:

2012 NFPA 99, 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, and 10.5.8

On 06/26/2019, during a tour of the facility from 2:00 pm to 3:30 pm, the facility failed to provide all of the following documentation on the PCREE:

1. File containing instruction manuals and maintenance manuals.
2. Documentation of the required testing, repairs, or modification of equipment.
3. Qualifications, training and continuous education of the personnel providing this service.

A member of the maintenance staff was present when this deficiency was identified.