HospitalInspections.org

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Based on observation, the facility failed to maintain a 2 hour horizontal exit per the requirements of:

2012 NFPA 101, 19.2.2.5, 7.2.4.3.1, and 8.3.5.1

This deficiency affects both sides of the 2 hour horizontal exit.

Findings include:

During a tour of the facility, the surveyor observed an unsealed penetration of a bundle of blue cables above the ceiling over the cross corridor doors, on both sides of the 2 hour horizontal exit, between the 200 Hall and the Nurses' Station.

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

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Based on review of documentation, the facility failed to provide documentation on the monthly testing of emergency lighting per the requirements of:

2012 NFPA 101, 19.2.9.1, and 7.9.3.1.1 (1) (5)

This deficiency affects all of the emergency lighting for the past 12 months.

Findings include:

During a tour of the facility, the facility failed to provide documentation of the monthly testing of the emergency lighting for the past 12 months.

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

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Based on review of documentation, the facility failed to maintain the alcohol-based hand-rub (ABHR) dispensers per the requirements of:

2012 NFPA 101, 19.3.2.6 (11) (f)

This deficiency affects all of the alcohol-based hand-rub (ABHR) dispensers.

Findings include:

During a tour of the facility, the facility failed to provide documentation regarding the testing per manufacturer's care and use instructions each time a new alcohol-based hand-rub (ABHR) dispenser refill is installed.

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

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

2012 NFPA 101, 19.3.4.1, 9.6.1.3, and 9.6.1.7
2010 NFPA 72, 14.2.1.2, 14.2.2, and Table 14.3.1(9)(h)

This deficiency affects the fire alarm system.

Findings include:

During a tour of the facility, the surveyor observed the following:

1. The FACP indicated the following troubles:

a. Ground Fault

b. Four audible/visible circuits

The staff stated the issues started after a recent lightning strike and the contractor is aware and making repairs, but failed to provide any documentation.

2. The facility failed to provide documentation of conducting semi-annual visual inspections on the smoke detectors within the past 12 months.

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

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45258

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Based on review of documentation, the facility failed to provide a fire alarm fire watch policy per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.6

This deficiency affects the whole building.

Findings include:

During a tour of the facility, the facility failed to provide a policy on the implementation of a fire watch in the event that any part of the fire alarm system is not operational for more than 4 hours in a 24 hour period of time.

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

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

2012 NFPA 101, 19.3.5.1, and 9.7.5
2011 NFPA 25, 5.3.1.1.1.3

This deficiency affects all of the 1998 fast-response sprinklers.

Findings include:

During a tour of the facility, the facility failed to provide documentation that the 1998 fast-response sprinklers found in the Front Lobby and throughout the facility had been replaced or a representative sample tested within 20 years of installation.

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

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Based on review of documentation, the facility failed to provide an automatic sprinkler system fire watch policy per the requirements of:

2012 NFPA 101, 19.3.5.3, and 9.7.5
2011 NFPA 25, 15.5.2 (4) (b)

This deficiency affects the whole building.

Findings include:

During a tour of the facility, the facility failed to provide a policy on the implementation of a fire watch in the event that any part of the sprinkler system is not operational for more than 10 hours in a 24 hour period of time.

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

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Based on observation, the facility failed to maintain a portable fire extinguisher per the requirements of:

2012 NFPA 101, 39.3.5, and 9.7.4.1
2010 NFPA 10, 7.2.1.2

This deficiency affects 1 of 1 portable fire extinguisher.

Findings include:

During a tour of the facility, the last monthly inspection documented on the fire extinguisher was June 2023.

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

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Based on observation, the facility failed to ensure the lay-in ceiling limited the transfer of smoke per the requirements of:

2012 NFPA 101, 19.3.6.2.4

This deficiency affects 3 of 9 ceiling tiles in one room.

Findings include:

During a tour of the facility, the surveyor observed the following missing ceiling tiles in the Front Hall Clean Utility Room:

1. Two, 2' x 2' tiles

2. One 2' x 4' tile

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

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Based on observation, the facility failed to maintain corridor doors per the requirements of:

2012 NFPA 101, 19.3.6.3.2
S&C-07-18

This deficiency affects 4 corridor doors.

Findings include:

During a tour of the facility the surveyor observed the following corridor doors with the following deficiencies:

1. Patient room 109 had a 5/8" gap between the door and door frame when the door was closed and latched

2. No positive latching on the following patient room corridor doors:

a. 113

b. 114

3. The Front Hall Housekeeping Storage Room had two unsealed penetrations at the corridor door handle:

a. 5/8" above

b. 1/4" below

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

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Based on observation, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and resist the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, and 8.5.6.2.

This deficiency affects 1 of 3 smoke barriers.

Findings include:

During a tour of the facility, the surveyor observed orange non-fire rated foam sealant was used to seal penetrations above the ceiling near room 109 in the smoke barrier.

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

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Based on review of documentation, the facility failed to maintain the dampers (smoke/fire/ceiling) per the requirements of:

2012 NFPA 101, 19.5.2.1, and 9.2.1
2012 NFPA 90A, 5.4.8.1, and 5.4.8.2
2010 NFPA 80, 19.4, and 19.5 (FIRE DAMPERS)
2010 NFPA 105, 6.5.2 (SMOKE DAMPERS)

This deficiency affects 12 of 12 dampers.

Findings include:

During a tour of the facility, the facility failed to provide documentation of testing the dampers (smoke/fire/ceiling) within the past 6 years.

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

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Based on a review of documentation, the facility failed to provide a written smoking policy per the requirements of:

2012 NFPA 101, 19.7.4

This deficiency affects 1 of 1 smoking policies.

Findings include:

Based on a review of documentation, the facility failed to provide a written smoking policy.

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

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Based on observation, the facility failed to prohibit a portable space heating device per the requirements of:

2012 NFPA 101, 19.7.8

This deficiency affects 1 smoke compartment.

Findings include:

During a tour of the facility, the surveyor observed a portable space heating device that was on and within 6" of a wood door, a wood book shelf with paper documents, and on a carpeted floor in the Nursing Supervisor's Office. This was located in a patient sleeping smoke compartment and the facility was unable to provide documentation that the heating element did not exceeding 212 degrees.

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

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Based on review of documentation, the facility failed to maintain the gas and vacuum piped system per the requirements of:

2012 NFPA 99, 5.1.14.4.1, 5.1.12.3.14.1, and 5.1.15

This deficiency affects the gas and vacuum piped systems.

During a tour of the facility, the facility failed to provide documentation of the annual inspection for the gas and vacuum piped system for the past 12 months.

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

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Based on review of documentation, the facility failed to maintain the receptacles not listed as hospital-grade at the patients' bed locations per the requirements of:

2012 NFPA 99, 6.3.4.1.3, and 6.3.3.2

This deficiency affects 6 of 8 smoke compartments.

Findings include:

During a tour of the facility, the facility failed to provide documentation of testing the receptacles not listed as hospital-grade at the residents' bed locations within the past 12 months.

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

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Based on observation, the facility failed to maintain the emergency generator's remote annunciator per the requirements of:

2012 NFPA 99, 6.4.1.1.17, 6.4.1.1.16.2, and Table 6.4.1.1.16.2 (k)

This deficiency affects 1 of 1 emergency generators.

Findings include:

During a tour of the facility, the surveyor observed the emergency generator's remote annunciator indicated "Not in Auto". Per observation the emergency generator's control switch was in auto. During the testing of the emergency generator, the emegrency generator did start automatically.

The staff stated the issue started after a recent lightning strike and the contractor is aware and making repairs, but failed to provide any documentation.

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

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Based on observation, the facility failed to maintain the Level 1 EES diesel generator per the requirements of:

2012 NFPA 101, 19.2.9.1, and 7.9.2.4
2010 NFPA 110, 5.6.5.6, and 5.6.5.6.1

2012 NFPA 99, 6.5.4.1.1.2, and 6.4.4.1.1.3
2010 NFPA 110, 8.3.7, 8.1.2, 8.4.1, 8.4.2.4, 8.3.8, and 8.3.4

This deficiency affects 1 of 1 emergency generator.

Findings include:

During a tour of the facility, the facility failed to provide the following for the emergency generator:

1. A remote manual stop station of a type to prevent inadvertent or unintentional operation
2. A label for the remote manual stop station
3. The facility failed to provide the following documentation on the emergency generator:
a. Weekly visual inspections
b. Exercised monthly for a minimum of 30 minutes with the available load
c. Annual diesel supplemental 1.5 hour load test
d. Level 1 EPSS 4 hour load bank test every 36 months
e. Annual fuel quality test approved by ASTM standards

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

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45258

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Based on observation, the facility failed to maintain the electrical equipment per the requirements of:

2012 NFPA 99, 10.2.3.6, and 10.2.4
2011 NFPA 70, 400.8
S&C: 14-46-LCS

This deficiency affects 1 patient room.

Findings include:

During a tour of the facility, the surveyor observed the following PCREE was plugged into an unapproved power strip (not a UL 1363A or a UL 60601-1) located within 2' of the patient bed in the Ultrasound Room/Patient Room 108:

1. A Patient Bed

2. An Ultrasound Machine

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