HospitalInspections.org

Based on observation, review of facility records, and staff interviews it was determine the facility failed to ensure exit access is so arranged that all exits are readily accessible at all times. 7.1 18.2.1 19.2.1


This could place 40% residents at risk in the event of an emergency.

The findings include:


During a review of facility records with Staff M on 02-08-16 between 09:00 am and 1:00 pm observation revealed that personnel protection station was six inch from the wall in the west wing (2EA) and the hand rails on the ramp leading from the emergency room needs to be turned under


These findings were confirmed by Staff M at the time of discovery

Based on observation,review of facility records, and staff interviews it was determine the facility failed to ensure that all fire drills were conducted per shift per quarter.18.7.1.2 19.7.1.2


This could place 30% residents at risk in the event of an emergency.


The findings include:


During a review of facility records with Staff M on 02-08-16 between 09:00 am and 1:00 pm recoords revealed that Faciltiy failed to ensure that fire alarm drill was conducted during second quarter first shift.


These findings were confirmed by Staff M at the time of discovery

Based on observation,review of facility records, and staff interviews it was determine the facility failed to ensure that the sprinkler head in the Sleep Study Storage Closet had the proper clearance 18 inch's. and the Emergency room was using quick responce sprinkler head's and standard responce sprinkler head's K56


This could place 40%residents at risk in the event of an emergency.


The findings include:


During a review of facility records with Staff M on 02-08-16 between 9:00 am and 1:00 pm Observation revealed that Sleep Study Storage closet Sprinkler head did not have the proper clearance 18 inch's and the emergency room was using quick responce heads and standard responce heads.


These findings were confirmed by Staff M at the time of discovery.

Based on observation,review of facility records and staff interviews it was determine the facility failed to ensure the the oxygen bottles were stored properly throughout the facility.NFPA 99


This could place 40% residents at risk in the event of an emergency.


The findings include:


During a review of facility records with Staff M on 02-08-16 between 09:00 am and 1:00 pm Observation revealed that oxygen bottles were improperly stored in the facility and was missing the proper signage also oxygen bottles in the outside storage area was not properly maintained.

These finding were confirmed by Staff M at the time of discovery.

Based on observation,review of facility records,and staff interviews it was determine the facility failed to ensure that Surge Protecter were not properly attach to the wall or to the furniture.NFPA 70


This could place 30% residents at risk in the event of an emergency.


The finding include:


During a review of facility records with Staff M on 02-08-16 between 9:00 am and 1:00 pm Observation revealed that facility failed to ensure that Surge Protecter in medical room and recods room were properly attach to the wall or to the furniture.


These findings were confirmed by Staff M at the time of discovery.