HospitalInspections.org

Based on observation and staff interview, the facility failed to maintain hazardous storage room doors per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.1, 19.3.2.1.3, and 8.7.1.1. These deficient findings could have a widespread impact on the patients within the facility.

Findings include:

On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by observation patient rooms 250-252, 254, 256, 262-268 and all rooms in the North Wing are being used for combustible storage and did not have a door closer on the doors.

An interview with the Director of Building and Grounds verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to maintain the fire alarm system per NFPA 101 (2012 edition), Life Safety Code, section 9.6.1.3, and NFPA 72 (2010 edition), National Fire Alarm and Signaling Code section 14.2.1.2.2. These deficient findings could have a widespread impact on the patients within the facility.

Findings include:

1. On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by a review of available documentation that the annual fire alarm inspection report could not be provide at the time of inspection.

2. On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by a review of available documentation that the fire alarm sensitivity report could not be provide at the time of inspection.

An interview with the Director of Building and Grounds verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to implement a fire alarm out-of-service policy per NFPA 101 (2012 edition), Life Safety Code, section 9.6.1.6. This deficient finding could have a widespread impact on the patients within the facility.

Findings include:

On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by a review of available documentation that the fire alarm out-of-service policy that was provided at the time of the survey did not have the current contact information.

An interview with the Director of Building and Grounds verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain single-station smoke alarms per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.4.1 and 9.6.2.10.1.1, and NFPA 72 (2010 edition), National Fire Alarm and Signaling Code, sections 29.10 and 14.4.8.1. This deficient finding could have a widespread impact on the patients within the facility.

Findings include:

On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by observation that the single-station smoke alarms located in the office of the COO were older than 10 years, and the batteries had been removed.

An interview with the Director of Building and Grounds verified these deficient findings at the time of discovery. .

Based on a review of available documentation and staff interview, the facility failed to implement a fire sprinkler out-of-service policy per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.5.1 and 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, section 15.5.2. This deficient finding could have a widespread impact on the patients within the facility.

Findings include:

On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by a review of available documentation that the fire sprinkler out of service policy did not have updated contact information for the Deputy State Fire Marshal that needs to be contacted in the event the fire sprinkler system is out of service.

An interview with the Director of Building and Grounds verified these deficient findings at the time of discovery.

Based on observation, review of available documentation and staff interview, the facility failed to properly inspect, and maintain documentation of portable fire extinguishers in accordance with NFPA 101 (2012 edition), Life Safety Code, sections 19.3.5.12, 9.7.4.1, and NFPA 10 (2010 edition), Standard for Portable Fire Extinguishers, section 6.1.3.3.1, 7.2.4.1, 7.2.4.5. These deficient findings could have a widespread impact on the patients within the facility.

Findings include:

1. On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by observation at the main entrance of the hospital the fire extinguisher by the Emergency Room door that is being held open by a magnetic hold open and is not easily accessible.

2. On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by observation that hang-tags on fire extinguishers indicated that the annual inspection was completed in March 2024 and the monthly inspections did not start until June 2024 throughout the facility.


An interview with the Director of Building and Grounds verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to inspect fire dampers per NFPA 101 (2012 edition), Life Safety Code, section 8.5.5.4.2, and NFPA 105 (2010 edition), Standard for Smoke Door Assemblies and Other Opening Protectives, section 6.5.2. This deficient finding could have a widespread impact on the patients within the facility.

Findings include:

On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by a review of available documentation that the facility could not provide current documentation of the fire dampers at the time of the survey.

An interview with the Director of Building and Grounds verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to implement a fire safety plan per NFPA 101 (2012 edition), Life Safety Code, section 19.7.2.2. This deficient finding could have a widespread impact on the patients within the facility.

Findings include:

On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by a review of available documentation that the fire safety plan that was provided at the time of the survey did not include the Transmission of the fire alarms to the fire department.

An interview with the Director of Building and Grounds verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to conduct fire drills per NFPA 101 (2012 edition), Life Safety Code sections 19.7.1.6. This deficient finding could have a widespread impact on the patients within the facility.

Findings include:

On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide any documentation showing that a fire drill had been completed during the last calendar year.

An interview with the Director of Building and Grounds verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to conduct fire drills per NFPA 101 (2012 edition), Life Safety Code sections 19.7.1.6. This deficient finding could have a widespread impact on the patients within the facility.

Findings include:

On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing that a fire drill had been completed during the third shift during the second quarter of 2024.

An interview with the Director of Building and Grounds verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to inspect fire doors per NFPA 101 (2012 edition), Life Safety Code section 8.3.3.1, and NFPA 80 (2010 edition), Standard for Fire Doors and Other Opening Protectives, section 5.2.1. This deficient finding could have a widespread impact on the patients within the facility.

Findings include:

On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by a review of available documentation at the time of the survey the facility could not provide proof that the repairs have been made since the annual fire door inspection on 11/14/2024.

An interview with the Director of Building and Grounds verified this deficient finding at the time of discovery.

Based on observation and document review, the facility did not implement a risk assessment procedure for building systems designed to meet Category 1 through 4 in accordance with NFPA 99, Chapter 4. This deficient finding could have a widespread impact on the patients within the facility

Findings include:

On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed that at the time of the survey, the facility was unable to provide documentation of the Facility Risk Assessment required under NFPA 99 Chapter 4.

An interview with the Director of Building and Grounds verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to install and maintain generators per NFPA 99 (2012 edition), Health Care Facilities Code, sections 6.4.4.1.1.4, 6.4.4.1.1.3, 6.4.1.1.16.2 and 6.4.1.1.17, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, sections 8.4.1, 8.4.2, 8.4.9, 8.4.9.1, 8.4.9.2 and 8.4.9.5.1. These deficient findings could have a widespread impact on the patients within the facility.

Findings include:

1. On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by a review of available documentation of the emergency generator maintenance and testing that the facility could not provide documentation that a 36 month four (4) hour load bank test had been performed.

2. On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by a review of available documentation of the emergency generator maintenance and testing that the facility could not provide documentation that the annual load bank test had been performed.

3. On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by a review of available documentation of the emergency generator maintenance and testing, that there were gaps in the weekly inspections for May and December 2024.

An interview with the Director of Building and Grounds 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 NFPA 99 (2012 edition), Health Care Facilities Code, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 101 (2012 edition), Life Safety Code, section 9.1.2, NFPA 70, (2011 edition), National Electrical Code, sections 400.8, and UL 1363. These deficient findings could have a patterned impact on the patients within the facility.

Findings include:

1. On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by observation that there was an extension cord plugged in the Director of Building and Grounds office.

2. On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by observation in the gift shop an extension cord and a multi-plug adapter in use.

An interview with the Director of Building and Grounds verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices NFPA 99 (2012 edition), Health Care Facilities Code, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 101 (2012 edition), Life Safety Code, section 9.1.2, NFPA 70, (2011 edition), National Electrical Code, sections 400.8, and UL 1363. These deficient findings could have a patterned impact on the patients within the facility.

Findings include:

1. On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by observation that there was an extension cord plugging in a water cooler by the stairwell.

2. On 01/28/2025 between 09:30 AM and 2:30 PM, it was revealed by observation in an employee charting area a microwave and small refridgerator was plugged into a powerstrip.

An interview with the Director of Building and Grounds verified this deficient finding at the time of discovery.