HospitalInspections.org

Based on observation and staff interviews it was determined that the designated exit by the ER nursing station exited through a storage room.

This could place 5 staff/residents at risk in the event of a fire.

The findings include:

During a tour of the facility with Staff M on
09/17/19 between 10:00 am and 1:00 pm observation revealed that the designated exit at the ER station was going through a storage room which is not allowed.

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

Reference: Horizontal Exits
NFPA 101 2012 Chapter 19 Section 19.2.2.5, Chapter 7 Section 7.2.4, 7.5.2.1

Based on observation and staff interviews it was determined the facility failed to have an electronic tamper device on the backflow preventer.

This could place 12 residents at risk in the event of a fire.

The findings include:

During a tour of the facility with Staff M on 09/17/19 between 10:00 am and 1:00 pm observation revealed that there was not an electronic tamper device on the back flow preventer.

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

Reference: OS&Y not supervised
NFPA 101-2012, chapter 19 Section 19.3.5.1, Chapter 9, Section 9.7.2.1*, NFPA 72, Chapter 17, Section 17.16.1.1, through 17.16.1.4

Based on observation and staff interviews it was determined that patient room doors 118, 131 and medical records door did not seal to the prevention of smoke. And Door in ER area had holes through the door.

This could place 5 resident/staff at risk in the event of a fire.

The findings include:

During a tour of the facility with Staff M on
09/17/2019 between 10:00 am and 1:00 pm observation revealed that patient room doors 118, 131, and the medical room door did not seal to the prevention of smoke. And the door in the ER area had holes through the door.

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

Reference: Resident room doors not tightly in frame
NFPA 101 2012 ED. CHAPTER 19 SECTION 19.3.6.3.1
Doors not maintained
2012 NFPA 101 Chapter 19 section 19.3.6.3, Chapter 4 section 4.6.12.1

Based on observation and staff interviews it was determined that flammable spray foam had been used to seal penetration through the fire rated walls above the Johnson Wing and the Med Surge area.

This could place 12 residents at risk in the event of a fire.

The findings include:

During a tour of the facility with Staff M on
09/17/19 between 10:00 am and 1:00 pm observation revealed that flammable spray foam had been used to seal penetration through the fire rated walls above the Johnson Wing and the Med Surge area.

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

Reference: Rated walls Penetrations not sealed properly with required rated materials
2012 NFPA 101 Chapter 19 sections 19.3.7.1, 19.3.7.3; Chapter 8 sections 8.5.6.3, 8.3.5

Based on observation and staff interviews it was determined the facility failed to have identification signage where oxygen tanks were being stored.

This could place 12 residents at risk in the event of an emergency needing oxygen and potential hazard.

The findings include:

During a tour of the facility with Staff M on
09/17/19 between 10:00 am and 1:00 pm observation revealed that where oxygen tanks were being stored no identification signage was present, no smoking sign and no full or empty identification signage.

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

Reference: Oxygen Storage signage (CAUTION: OXIDIZING)
2012 NFPA 101 Chapter 19, Section 19.3.2.4, Chapter 8 Section 8.7, 2012 NFPA 99 Chapter 11 Section 11.3.4.1 & 11.3.4.2
Oxygen Storage empty and full stored in same enclosure not segregated between empty & full
2012 NFPA 101 Chapter 19, Section 19.3.2.4, Chapter 8 Section 8.7, 2012 NFPA 99 Chapter 11, Section 11.6.5.2
Oxygen Storage not marked empty & full
2012 NFPA 101 Chapter 19, Section 19.3.2.4, Chapter 8 Section 8.7, 2012 NFPA 99 Chapter 11, Section 11.6.5.3