HospitalInspections.org

K200 Means of Egress Requirements - General
Findings:
The inspector observed, while accompanied by the CEO, during the hours of the inspection from 3:00 pm to 5:00 pm on 04/06/2023, that there were the following issues:
1) Based on review of the records, facility failed to perform inspection of doors in means of egress annually.

K223 Doors with Self-Closing Devices
Findings:
The inspector observed, while accompanied by the CEO, during the hours of the inspection from 3:00 pm to 5:00 pm on 04/06/2023, that there were the following issues:
1) Observed during tour, the double door with magnetic hold opening into the inpatient unit was missing an astragal.

K353 Sprinkler System - Maintenance and Testing
Findings:
The inspector observed, while accompanied by the CEO, during the hours of the inspection from 3:00 pm to 5:00 pm on 04/06/2023, that there were the following issues:
1) Observed during tour in patient storage room, there was a sprinkler head with missing escutcheon cover
2) Observed during tour in seclusion anteroom, the sprinkler head protruded out too much and should be flush with the ceiling tile.

K355 Portable Fire Extinguishers
Findings:
The inspector observed, while accompanied by the CEO, during the hours of the inspection from 3:00 pm to 5:00 pm on 04/06/2023, that there were the following issues:
1) Observed during tour, facility failed to show records demonstrating fire extinguishers were subject to maintenance at yearly interval on a consistent basis.
2) The fire extinguisher monthly check failed to consistently note the date it was checked.

K500 Building Services - Other
Findings:
The inspector observed, while accompanied by the CEO, during the hours of the inspection from 3:00 pm to 5:00 pm on 04/06/2023, that there were the following issues:
1) Based on review of the records, facility failed to keep logs of when filters were changed for each air handler serving the facility.

K700 Emergency Preparedness Plan and Drills
Findings:
The inspector observed, while accompanied by the CEO, during the hours of the inspection from 3:00 pm to 5:00 pm on 04/06/2023:
1) Based on review of the records, facility failed to participate and provide written report on community mock disaster drill annually.

K712 Fire Drills
Findings:
The inspector observed, while accompanied by the CEO, during the hours of the inspection from 3:00 pm to 5:00 pm on 04/06/2023:
1) Based on review of the records, facility failed to perform fire drill on a consistent basis. For example, there was no record of fire drill from January to April of 2022. Even though facility indicated a change in leadership, there should be a systemic record keeping that persists through personnel change.

K741 Smoking Regulations
Findings:
The inspector observed, while accompanied by the CEO, during the hours of the inspection from 3:00 pm to 5:00 pm on 04/06/2023:
1) Observed during tour, "NO SMOKING" not prominently displayed at all major entrances.

K901 Fundamentals - Building System Categories
Findings:
The inspector observed, while accompanied by the CEO, during the hours of the inspection from 3:00 pm to 5:00 pm on 04/06/2023:
1) Based on review of the records, facility failed to date the annual risk assessment.

K912 Electrical Systems - Receptacles
Findings:
The inspector observed, while accompanied by the CEO, during the hours of the inspection from 3:00 pm to 5:00 pm on 04/06/2023, that there were the following issues:
1) Observed during tour in soiled utility room, there was a non-operational GFCI receptacle outlet near hopper sink that needed replacement.

K921 Biomedical electrical inspection reports
Findings:
The inspector observed, while accompanied by the CEO, during the hours of the inspection from 3:00 pm to 5:00 pm on 04/06/2023, that there were the following issues:
1) Based on review of the records, facility failed to perform biomedical equipment inspection annually.