HospitalInspections.org

SPECIAL LOCKING ---EXIT DOORS

Based on visual observation the facility failed to provide free egress from all required exits. Access to an unobstructed exit provides occupants with a sense of security to remain calm when an emergency occurs. The deficient practice had the potential to affect 40 of 40 residents.

1 of 10 doors are deficient

Findings:

During the facility tour and interview with staff on February 1, 2024 revealed that the door to the road had a padlock securing the door. The door shall be permitted using one or more of the three listed options and panic hardware installed as well.

When special locking devices are permitted one of three options is required in order to allow free egress for staff and visitors. The three options are:

1. The access code for the keypad is posted at the device, or,
2. The key to the override switch is posted at the device, or,
3. Staff carry a key to the override switch at all times

Interview with plant operations manager revealed the facility was not aware that one of the three options is required in order to exit from the building.

K324 Cooking Facilities
Based on visual observation and record review the facility failed to assure that semi-annual inspections and routine cleanings were conducted by a licensed contractor on the commercial hood/suppression system. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system. The deficient practice had the potential to affect 277of 277 residents.

Findings:

During the record review on February 1, 2024 revealed that the semi-annual suppression inspection was past due 1/30/2023. Contractor
should be on site 2/12/2024

Interview with plant operations manager revealed the facility was aware the semi-annual inspection was not conducted on the hoop suppression system but the contractor could not perform the inspection until 2/12/2024

K345 Fire Alarm System - Testing and Maintenance
Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 277 of 277 residents.

Findings:
During the facility tour and the record review on February 1, 2024 revealed that the annual inspection had not been completed.

Interview with plant operations director revealed the facility was aware that the required inspections had not been conducted on the fire alarm system but the earliest the contractor could conduct the inspection was 2/12/2024

K353 Sprinkler System - Maintenance and Testing
Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect of residents.

Findings:

During the facility tour on February 1, 2024 revealed that the sprinkler system was past due for annual inspection and the sprinkler system pump had a leak from the packing.

Interview with plant operations manager revealed the facility was aware that the annual and/or quarterly inspections had not been conducted on the automatic sprinkler system but the contractor was scheduled to arrive on site 2/12/2024

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protectives. Fire doors that are not located in required fire barriers, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspection and testing have an understanding of the operating components of the doors. Written records of inspection and testing are maintained and are available for review.18.7.6, 19.7.6, 8.3.3.1 (LSC), 5.2, 5.2.3 (NFPA 80).

Based on visual observation and record review the facility had the fire doors inspected and repaired some doors. This deficiency has the potential to affect 277 of 277 residents.

Findings:

During the facility tour and record review on February 1, 2024 revealed that the fire door assemblies were inspected but some doors were repaired under a phase 1 work and the remaining door deficiencies are to be repaired under a phase II. The phase II contract has been received but has not been approved by the facility. The complete fire door report has been filed under the OFSM IMS program under attachments.

Interview with plant operations manager revealed the facility was aware of the fire door deficiencies but the facility was unable to pay for all of the fire door repairs so the repair was split up into two phases.

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protectives. Fire doors that are not located in required fire barriers, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspection and testing have an understanding of the operating components of the doors. Written records of inspection and testing are maintained and are available for review.18.7.6, 19.7.6, 8.3.3.1 (LSC), 5.2, 5.2.3 (NFPA 80).

Based on visual observation and record review the facility had the fire doors inspected and repaired some doors. This deficiency has the potential to affect 4 of 4 residents.

Findings:

During the facility tour and record review on February 1, 2024 revealed that the fire door assemblies were inspected but some doors were repaired under a phase 1 work and the remaining door deficiencies are to be repaired under a phase II. The phase II contract has been received but has not been approved by the facility. The complete fire door report has been filed under the OFSM IMS program under attachments.

Interview with plant operations manager revealed the facility was aware of the fire door deficiencies but the facility was unable to pay for all of the fire door repairs so the repair was split up into two phases.

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protectives. Fire doors that are not located in required fire barriers, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspection and testing have an understanding of the operating components of the doors. Written records of inspection and testing are maintained and are available for review.18.7.6, 19.7.6, 8.3.3.1 (LSC), 5.2, 5.2.3 (NFPA 80).

Based on visual observation and record review the facility had the fire doors inspected and repaired some doors. This deficiency has the potential to affect 40 of 40 residents.

Findings:

During the facility tour and record review on February 1, 2024 revealed that the fire door assemblies were inspected but some doors were repaired under a phase 1 work and the remaining door deficiencies are to be repaired under a phase II. The phase II contract has been received but has not been approved by the facility. The complete fire door report has been filed under the OFSM IMS program under attachments.

Interview with plant operations manager revealed the facility was aware of the fire door deficiencies but the facility was unable to pay for all of the fire door repairs so the repair was split up into two phases.

Based on visual observation the facility failed to assure the med gas inspection deficiencies listed on 12/08/2023 inspection report was repaired per Nfpa 99. This deficiency has the potential to affect 277 of 277 residents.

Findings:

During the facility tour and records review on February 1, 2024 revealed that the med gas was inspected but the deficiencies were not repaired per Nfpa 99. A list of deficiencies are attached to the OSFM IMS site under attachments.

Interview with plant operations manager revealed the facility was aware of the deficiencies of the med gas report but the approval to repair the deficiencies had not been granted by the corporate office.

Based on visual observation the facility failed to assure the med gas inspection deficiencies listed on 12/08/2023 inspection report was repaired per Nfpa 99. This deficiency has the potential to affect 4 of 4 residents.

Findings:

During the facility tour and records review on February 1, 2024 revealed that the med gas was inspected but the deficiencies were not repaired per Nfpa 99. A list of deficiencies are attached to the OSFM IMS site under attachments.

Interview with plant operations manager revealed the facility was aware of the deficiencies of the med gas report but the approval to repair the deficiencies had not been granted by the corporate office.