HospitalInspections.org

Based on observation and interview, the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 485.623(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include:

See tag:

C-0930 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

Based on interview and record review, the hospital failed to provide a preventative maintence program for mechanical equipment in the hospital resulting in potential failure of mechanical equipment that could result in bad outcomes for all patients being treated at the hospital. Findings include:

On 12/18/24 at approximately 10:00 am, records were requested for preventative maintenance that was performed on the air handling units and exhaust fan units serving the hospital and Staff U could not provide these records. Staff U was asked why a program was not created. Staff U stated that they haven't been able to create one since they have been recently hired onto the staff of the hospital.

Based on observation and interview, the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 485.623(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include:

See specific K tags on the LSC survey:
K0291
K0321
K0324
K0908
K0918
K0923