HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure that smoke barriers were constructed and maintained to the appropriate fire resistance rating in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced.

Findings include:

During the facility inspection tour conducted on 09/06/23 at 10:15 a.m. revealed non-rated expandable foam in four penetrations above the ceiling in the corridor by Cardiopulmonary Rehabilitation.

Interview on 09/06/23 at approximately 10:17 a.m. with the Facilities Maintenance Director verified these findings. The findings were were also acknowledged by the Administrator at the exit interview on 09/06/23.

Based on observation and staff interview, the facility failed to maintain the Sprinkler System in accordance with NFPA (National Fire Protection Association) 101 and 25. This deficient practice could affect all residents, staff, and visitors in the areas referenced.

Findings include:

During a facility tour on 09/06/23 at 10:35 a.m. revealed wiring on the sprinkler pipe in the Service Hall by the Materials Management room.

Interview on 09/06/23 at approximately 10:40 a.m. with the Facility Maintenance Supervisor verified these findings. The findings were also acknowledged by the Administrator at the exit interview on 09/06/23.

Based on observation and staff interview, the facility failed to maintain the Corridor Walls in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced.

Findings include:

An observation on 09/06/23 at 10:24 a.m. revealed a penetration in the Firewall above ceiling in the corridor by room 411.

An observation on 09/06/23 at 10:30 a.m. revealed a penetration in the Firewall above ceiling in the service hall corridor across from the door to the kitchen dish washing room.

Interview on 09/06/23 at approximately 10:40 a.m. with the Facility Maintenance Supervisor verified these findings. The findings were also acknowledged by the Administrator at the exit interview on 09/06/23.

Based on observation and staff interview, the facility failed to ensure that electrical wiring and equipment shall be in accordance with NFPA (National Fire Protection Association) 70. This deficient practice could affect all residents, staff, and visitors in the areas referenced.

Findings include:

Observation on 09/06/23 at approximately 10:15 a.m., revealed an uncovered electrical junction box located above ceiling in the corridor by Cardiopulmonary Rehabilitation

Observation on 09/06/23 at approximately 10:30 a.m., revealed an uncovered electrical junction box located above ceiling in the corridor by the entrance to the Long Term Care.

Interview on 09/06/23 at approximately 10:35 a.m. with the Facility Maintenance Supervisor verified these findings. The findings were also acknowledged by the Administrator at the exit interview on 09/06/23.

Based on observation and staff interview, the facility failed to maintain Electrical Equipment-Testing and Maintenance in accordance with NFPA (National Fire Protection Association) 101 and 99. This deficient practice could affect all residents, staff, and visitors in the areas referenced.

Findings include:

a) Record review on 09/05/23 at 1:30 p.m. revealed no evidence of the physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE).

b) Interview on 09/06/23 at approximately 12:30 p.m. with the Facility Maintenance Supervisor verified these findings. The findings were also acknowledged by the Administrator at the exit interview on 09/06/23.