HospitalInspections.org

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Based on observation, the facility failed to maintain a hazardous room open to the corridor per the requirements of:

2012 NFPA 101, 19.3.2.1.3

This deficiency could affect approximately 15 occupants.

Findings include:

On 12/17/2019, during a tour of the facility from 9:30 am to 3:30 pm, the surveyor observed the corridor door with a self-closing device to the Floor Equipment Storage Room had been removed. This room was over 50 sq. ft. with combustibles and hazardous materials.

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

2012 NFPA 101, 9.7.5
2011 NFPA 25, 5.3.1.1.1.6

This deficiency could affect approximately 15 occupants.

Findings include:

On 12/17/2019, during a tour of the facility from 9:30 am to 3:30 pm, the facility failed to provide documentation that the dry sprinkler heads installed in 1992 in the walk in cooler and freezer had been replaced or a representative sample tested within 10 years of installation.

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

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Based on observation, the facility failed to install the portable fire extinguishers per the requirements of:

2012 NFPA 101, 19.3.5.12, and 9.7.4.1
2010 NFPA 10, 6.1.3.8.1

This deficiency could affect approximately 25 occupants.

Findings include:

On 12/17/2019, during a tour of the facility from 9:30 am to 3:30 pm, the surveyor observed portable fire extinguishers installed approximately 67" from the floor to the top of the fire extinguishers in the following locations:

1. At the Outpatient Exit
2. In Mechanical Room #4

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to maintain a smoke barrier 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, 8.5.6.2, and 8.5.6.3

This deficiency could affect approximately 20 occupants.

Findings include:

On 12/17/2019, during a tour of the facility from 9:30 am to 3:30 pm, the surveyor observed the following:
1. An unsealed approximately 1" flexable conduit penetrating the smoke barrier in Data Proccessing
2. Non rated foam sealant used to seal penetrations in the barrier at Patitents' 200 Wing

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation, the facility failed to conduct fire drills per the requirements of:

2012 NFPA 101, 19.7.1.6, 4.7.2, and 4.7.4

This deficiency could affect approximately all occupants.

Findings include:

On 12/17/2019, during a tour of the facility from 9:30 am to 3:30 pm, the facility provided the following documentation:
First Shift
11/29/19 - 1:30 pm
08/30/19 - 1:50 pm
05/24/19 - 12:20 pm
02/08/19 - 9:20 am

Second Shift
12/14/19 - 4:30 pm
09/23/19 - 4:20 pm
06/18/19 - 4:30 pm
03/29/19 - 3:50 pm

All drills for the Second Shift were conducted within 40 minutes for an eight hour shift for the past 12 months.

Third Shift
10/29/19 - 11:05 pm
07/23/19 - 6:00 am
04/30/19 - 11:05 pm
01/10/19 - 5:00 am

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

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Based on review of documentation, the facility failed to maintain the piped oxygen per the requirements of:

2012 NFPA 99, 5.1.14.2.1, 5.1.14.2.2, and 5.1.15

This deficiency could affect all occupants

On 12/17/2019, during a tour of the facility from 9:30 am to 3:30 pm, the facility failed to provide documentation of the annually inspection for the piped medical gases.

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

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Based on review of documentation, the facility failed to maintain the testing of the diesel generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, 8.4.1, 8.4.2, 8.4.2.3,8.3.8 and 8.4.9

This deficiency could affect approximately 20 occupants.

Findings include:

On 12/17/2019, during a tour of the facility from 9:30 am to 3:30 pm, the facility failed to:

1. Test the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature OR under operating temperature conditions at not less than 30% of the nameplate kW rating OR provide an annual 1.5 hour supplemental load test at not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less 75% of the EPS nameplate KW rating for one continuous hour for a total test duration of not less than 1.5 continuous hours.

2. To have a fuel quality test performed at least annually using tests approved by ASTM standards.

3. To have a level 1 EPSS test performed at least once within every 36 months.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to maintain the electrical equipment per the requirements of:

2012 NFPA 99, 10.2.3.6, and 10.2.4
2011 NFPA 70, 400.8

This deficiency could affect approximately 10 occupants.

Findings include:

On 12/17/2019, during a tour of the facility from 9:30 am to 3:30 pm, the surveyor observed a computer plugged into a yellow extension cord under a desk in the Pharmacy.

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