HospitalInspections.org

.

Based on observation, the facility failed to provide continuous illumination of the exit signage per the requirements of:

2012 NFPA 101, 19.2.10.1, and 7.10.5.2.1

This deficiency could affect approximately 30 occupants.

Findings include:

On 02/18/2020, during a tour of the facility from 8:30 am to 3:30 pm, the surveyor observed the exit sign near the "Old Lab Office" was not illuminated.

A member of the maintenance staff was present when the deficiency was identified.

.

.

Based on observation, the facility failed to maintain the hazardous rooms per the requirements of:

2012 NFPA 101, 19.3.2.1.2, and 19.3.2.1.3

This deficiency could affect approximately 20 occupants.

Findings include:

On 02/18/2020, during a tour of the facility from 8:30 am to 3:30 pm, the surveyor observed the "Old Lab's" door did not have a self-closing device; this room is near Lab Registration, was over 50 sq. ft. and cardboard boxes, and stacks of cases of copy paper (combustibles) were being stored in the room.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation, the facility failed to maintain a hazardous room per the requirements of:

2012 NFPA 101, 19.3.2.1.2, and 19.3.2.1.3

This deficiency could affect approximately 20 occupants.

Findings include:

On 02/18/2020, during a tour of the facility from 8:30 am to 3:30 pm, the surveyor observed the Med Surge Room's door did have a self-closing device; this room was over 50 sq. ft. with storage of card board boxes (combustibles).

A member of the maintenance staff was present when this deficiency was identified.
.

.

Based on observation, the facility failed to install Alcohol-Based Hand-Rub (ABHR) Dispensers per the requirements of:

2012 NFPA 101, 19.3.2.6 (8)

This deficiency could affect approximately 30 occupants.

Findings include:

On 02/18/2020, during a tour of the facility from 8:30 am to 3:30 pm, the surveyor observed ABHR Dispensers mounted directly above an electrical outlet (ignition source) at the following loacations:
1. Near Rooms 138 and 139
2. Near Rooms 142 and 143

A member of maintenance staff was present when this deficiency was identified.
.

.

Based on observation, the facility failed to maintain a visual device for the fire alarm system per the requirements of:

2012 NFPA 101, 19.3.4.1, 9.6.1.3, 9.6.1.7, and 9.6.3.6.1
2010 NFPA 72, 10.9.2, and 18.5.2

This deficiency could affect approximately 10 occupants.

Findings include:

On 02/18/2020, during a tour of the facility from 8:30 am to 3:30 pm, the surveyor observed the only visual strobe device in the Hospice Office failed to flash when the fire alarm was activated.

A member of the maintenance staff was present when this deficiency was identified.
.

.

Based on observation, the facility failed to ensure synchronization of the visible notification devices for the fire alarm system per the requirements of:

2012 NFPA 101, 19.3.4.3.1, and 9.6.3.5
2010 NFPA 72, 18.5.4.4.7

This deficiency could affect approximately 35 occupants.

Findings include:

On 02/18/2020, during a tour of the facility from 8:30 am to 3:30 pm, during activation of fire alarm system the surveyor observed three fire alarm notification devices in the field of view in the dinning room not flashing in synchronization.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation and review of documentation, the facility failed to maintain the fire alarm system per the requirements of:

2012 NFPA 101, 9.6.1.3
2010 NFPA 72, 14.4.5, and Table 14.4.5

This deficiency could affect all occupants.

Findings include:

On 02/18/2020, during a tour of the facility from 8:30 am to 3:30 pm, the facility failed to provide documentation that an annual fire alarm inspection was conducted within the past 12 months. The last documented inspection report was dated 02/10/2018.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation, the facility failed to provide ceilings required for the pendant sprinklers in the facility per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.1.1 (1)
2010 NFPA 13, 8.5.1.1, 8.5.1.2, and 8.5.4.2

This deficiency could affect approximately 30 occupants.

Findings include:

On 02/18/2020, during a tour of the facility from 8:30 am to 3:30 pm, the surveyor observed several 2' x 4' ceiling tiles was missing in the Old Lab Department.

A member of the maintenance staff was present when this deficiency was identified.
.

.

Based on observation and review of documentation, the facility failed to maintain the automatic sprinklers per the requirements of:

2012 NFPA 101, 9.7.5
2011 NFPA 25, 5.3.1.1.1.6, and 5.2.4.1

This deficiency could affect approximately 15 occupants.

Findings include:

On 02/18/2020, during a tour of the facility from 8:30 am to 3:30 pm, the observed the following:

1. The facility failed to provide documentation that the dry sprinklers installed in the walk in cooler and freezer in 2008, had been replaced or a representative sample tested within 10 years of installation.
2. The facility failed to provide documentation of the monthly inspections on the wet sprinkler guages.

A member of the maintenance staff and the administrator were present when this deficiency was identified.

.

.

Based on review of documentation, the facility failed to conduct fire drills per the requirements of:

2012 NFPA 101, 19.7.1.6, 4.7.2, and 4.7.4

This deficiency could affect all occupants.

Findings include:

On 02/18/2020, during a tour of the facility from 8:30 am to 3:30 pm, the facility provided the following documentation:
First Shift
01/31/2020 - 9:15 am
10/30/2019 - 1:00 pm
07/31/2019 - 1:15 pm
NO DRILL for second quarter of 2019

Second Shift
11/27/2019 - 4:00 pm
09/30/2019 - 10:30 pm
04/24/2019 - 4:00 pm
02/20/2019 - 7:12 pm

Third Shift
NO DRILL for fourth quarter of 2019
NO DRILL for third quarter of 2019
05/21/2019 - 11:06 pm
NO DRILL for first quarter of 2019

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation, the facility failed to maintain the designated smoking area per the requirements of:

2012 NFPA 101, 19.7.4 (6)

This deficiency could affect approximately 15 occupants.

Findings include:

On 02/18/2020, during a tour of the facility from 8:30 am to 3:30 pm, the surveyor observed combustable trash in both of the metal contaners with self-closing devices.

A member of the maintenance staff was present when this deficiency was identified.
.

.

Based on review of documentation, the facility failed to maintain the testing of the Level 1 EPSS diesel generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, 8.4.2, 8.4.2.3, 8.3.8, and 8.4.9

This deficiency could affect approximately all occupants.

Findings include:

On 02/18/2020, during a tour of the facility from 8:30 am to 3:30 pm, the facility failed to:

1. Test the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature OR under operating temperature conditions at not less than 30% of the nameplate kW rating OR provide an annual 1.5 hour supplemental load test at not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less 75% of the EPS nameplate KW rating for one continuous hour for a total test duration of not less than 1.5 continuous hours.

2. To have a fuel quality test performed at least annually using tests approved by ASTM standards.

3. To have a Level 1 EPSS test conducted within the past 36 months.

A member of the maintenance staff was present when this deficiency was identified.