HospitalInspections.org

Based on record review and interview, the facility failed to conduct required fuel inspection of the emergency generator. This deficient practice would not ensure the emergency generator would operate upon loss of normal power. The facility had a census of 3 on the day of survey.

Findings are:
During record review on 3-11-25 at 9:44 am, the facility failed produce documentation to assure a yearly fuel test was conducted on the fuel for the emergency generator.

During an interview on 3-11-25 at 9:44 am, Maintenance Staff A and B confirmed the lack of fuel testing.

Based on observation and interview, the facility allowed abrupt changes in the elevation of the walking surfaces in a path of egress that exceeded 1/2 inch. This deficient practice could slow evacuation of the facility. The facility census on the day of survey was 3.

Findings are:
Observations on 3-11-25 from 11:20 am to 11:32 am revealed the following.
1. The east sidewalk egress path from the front door had abrupt one-inch changes in elevation and several holes of missing concrete.
2. The southwest sidewalk egress path from the south door had abrupt one-inch changes in elevation and several holes of missing concrete.

During interviews on 3-11-254 between 11:20 am and 11:32 am, Maintenance Staff A and B confirmed the findings on the sidewalk.

Based on documentation review, observation and interview, the facility failed to provide documentation of biennial sensitivity testing of the smoke detectors. This deficient practice would cause the fire alarm system to fail to activate in a timely manner. The facility had a census of 3 on the day of survey.

Findings are:
Record review on 3-11-25 at 10:22 am revealed the lack of documentation of biennial sensitivity testing for the smoke detectors in the facility.

During an interview on 3-11-25 at 10:22 am Maintenance Staff A and B confirmed the findings.

Based on documentation review and interview, the facility failed to provide documentation of 5-year internal inspection of the fire sprinkler system piping. This deficient practice would cause the fire sprinkler system to fail to flow the required volume of water and could plug fire sprinklers during a fire. The facility had a census of 3 on the day of survey.

Findings are:
Record review on 3-11-25 at 10:02 am revealed the lack of documentation of 5-year internal inspection of the fire sprinkler system. The last documented test was performed in 2018.

During an interview on 3-11-25 at 10:02 am, Maintenance Staff A and B confirmed the findings.

Based on record review and interview, the facility failed to conduct required fuel inspection of the emergency generator. This deficient practice would not ensure the emergency generator would operate upon loss of normal power. The facility had a census of 3 on the day of survey.

Findings are:
During record review on 3-11-25 at 9:44 am, the facility failed produce documentation to assure a yearly fuel test was conducted on the fuel for the emergency generator.

During an interview on 3-11-25 at 9:44 am, Maintenance Staff A and B confirmed the lack of fuel testing.