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Based on observation and staff interview, the facility failed to maintain a clear path of egress system per NFPA 101 (2012 edition), Life Safety Code, sections 19.2.1 and 7.1.10.1. This deficient finding could have a patterned impact on the residents within the facility.

Findings include:

On 10/15/2024, between 0730am and 1130am, it was revealed by observation that there was medical equipment in the egress corridor in the following areas:

1) Imaging hallway
2) Materials Management Area

An interview with Director of Environmental Services verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to install self-closing device per NFPA 101 (2012 edition), Life Safety Code, section 19.2.2.5, 19.2.2.5.1 through 19.2.2.5.4 and chapter 7, section 7.2.4 These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 10/15/2024, between 0730am and 1130am, it was revealed by observation that the egress vestibule in the Material Management area was filled with medical materials and boxes.

An interview with Director of Environmental Services verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to install self-closing device per NFPA 101 (2012 edition), Life Safety Code, section 19.2.2.5, 19.2.2.5.1 through 19.2.2.5.4 and chapter 7, section 7.2.4 These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 10/15/2024, between 0730am and 1130am, it was revealed by observation that the egress path in the Material Management area was filled with medical materials and boxes.

An interview with Director of Environmental Services verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain hazardous storage rooms per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.1.3 and 7.2.1.8.1. These deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 10/15/2024, between 0730am and 1130am, it was revealed by observation that hospital room that has been converted to a storage room did not have a self-closing device.

An interview with Director of Environmental Services verified these deficient findings at the time of discovery.

1) Based on observation and staff interview, the facility failed to maintain spacing between storage and the sprinkler system per NFPA 101 (2012 edition), Life Safety Code, Section 9.7.5, NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 5.2.1.2, and NFPA 13 (2010 edition), Standard for the Installation of Sprinkler Systems, Sections 8.6.5.3.2 and 8.15.9. These deficient findings could a patterned impact on the residents within the facility.

Findings include:

On 10/15/2024, between 0730am and 1130am, it was revealed by observation that storage materials had been placed on a storage rack, bringing the storage materials within the required 18 inch clearance area under the sprinkler heads. These obstructions were found in:

1) Med room in hospital
2) On top of refrigerator in Lab
3) Shelves in Imaging - Mammography Office
4) On top of refrigerator in Pharmacy
5) Shelves in shipping & Receiving in Materials Management area
6) Occupational Therapy
7) Clean Linen room in main hall way

2) Based on observation and staff interview, the facility failed to maintain the automatic fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), the Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, section 5.4.1.4, and 5.4.1.4.2. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 10/15/2024, between 0730am and 1130am, it was revealed by observation that there were unsecured fire sprinkler heads that were not protected from being damaged, stored loosely within the spare sprinkler head boxes located by the fire sprinkler riser room.

An interview with Director of Environmental Services verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain their smoke barrier per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.1, 19.3.7.3, 8.5.2.2, and 8.5.6.5. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 10/15/2024, between 0730am and 1130am, it was revealed by observation that there was a penetration running from one smoke compartment to another above doors in the main hallway between hospital and nursing home around the emergency room entrance.

An interview with Director of Environmental Services verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the electrical system per NFPA 101 (2012 edition), Life Safety Code, section 9.1.2, and NFPA 70 (2011 edition), National Electrical Code, section 406.6. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 10/15/2024, between 0730am and 1130am, it was revealed by observation that there was a missing cover on an electrical junction box in the electrical room (Switch Gear Room)

An interview with Director of Environmental Services verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices per NFPA 99 (2012 edition), Health Care Facilities Code, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 70, (2011 edition), National Electrical Code, sections 400-8, and UL 1363. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 10/15/2024, between 0730am and 1130am, it was revealed by observation that there were several electrical appliances plugged power-strips, multi-plug adapters and/or extension cords in the following areas;

1) Power-strip in EMS Coordinator Office
2) Power-strip in Break area in Imaging
3) Multi-plug in Doctor Sleeping room
4) Power-strip in House Keepers Office
5) Power-strip in Ambulance Garage
6) Power-strip in office area outside of the Board Room

An interview with Director of Environmental Services verified these deficient findings at the time of discovery.