HospitalInspections.org

Based on observation and interview, the provider failed to maintain proper separation of two randomly observed hazardous areas (electrical rooms E613 and E614). Findings include:

1. Observation at 1:45 p.m. on 4/12/16 revealed several openings around conduit pipe penetrations in the walls of electrical rooms E613 and E614 that were not sealed with an appropriate firestop material. Interview with the environmental services supervisor at the time of the observation confirmed that finding. He stated the conduit installations had been done at the time of the nursing home construction in 2014.

The deficiency affected one of three smoke compartments.

Based on observation and interview, the provider failed to maintain the required exit corridor width at the south end of the patient wing (day room area). Findings include:

1. Observation at 3:15 p.m. on 4/12/16 revealed the day room area (south end of the patient wing) was located in the exit corridor. The corridor area had multiple benches, tables, and chairs which restricted the corridor width from the required eight feet to just 30 inches. Interview with the administrator at the time of the observation confirmed that finding.

The deficiency has the potential to affect egress exit ability for all occupants of that smoke compartment.

A. Based on observation, testing and interview, the provider failed to maintain the battery pack emergency light for the generator transfer switch at one of two locations (electrical room 614). Findings include:

1. Observation at 1:45 p.m. on 4/12/16 revealed electrical room E614 had a transfer switch located in the room. There was a battery pack emergency light located in the room. Testing of that emergency light at the time of the observation revealed the lamps did not function. Interview with the envionmental services supervisor at the time of the observation confirmed that finding. He added that light was not yet on his preventive maintance list.

The deficiency affected one of numerous requirements for generator installations.

Based on observation and interview, the provider failed to install a battery pack emergency light for the generator transfer switch in electrical room E613. Findings include:

2. Observation at 2:15 p.m. on 4/12/16 revealed there was a generator transfer switch located in electrical room E613. There was not a battery pack emergency light located in that room. Interview with the environmental services supervisor at 2:00 p.m. on 4/12/16 indicated he was unaware of the requirement for the emergency lighting at the transfer switch location.

The deficiency affected one of numerous requirements for generator installations.

B. Based on interview and document review, the provider failed to conduct five minute cool-down periods following the required thirty minute monthly emergency generator load tests for 2015. Findings include:

1. Interview with the environmental services supervisor at 2:45 p.m. on 4/12/16 revealed the emergency generator was exercised weekly with a load test performed once per month. Review of the generator log (hour meter readings) revealed the load test runs were performed for a period of thirty minutes. A five minute cool-down run time is required after the thirty minute load run. Interview with the environmental services supervisor at 3:00 p.m. on 4/12/16 indicated he was unaware of the requirement for the five minute cool-down period following the full load test.

The deficiency had the potential to affect 100% of the building occupants.

Based on observation and interview, the provider failed to maintain a 36 inch clear depth of working space in front of three of three electrical panels (in the clean utility room). Findings include:

1. Observation at 1:45 p.m. on 4/12/16 revealed electrical panels LCBC, LNC, and LEQC in the clean utility room had three carts placed directly in front of them. There were no markings on the floor to show the depth of space required to be kept clear for the electrical panels. Interview with the environmental services supervisor at the time of the observation confirmed that condition. He stated staff assumed since the shelving/carts were on wheels, the depth of working space requirement did not have to be maintained.

The deficiency affected one of numerous requirements for electrical installations.

Based on observation and interview, the provider failed to maintain proper separation of two randomly observed hazardous areas (electrical rooms E613 and E614). Findings include:

1. Observation at 1:45 p.m. on 4/12/16 revealed several openings around conduit pipe penetrations in the walls of electrical rooms E613 and E614 that were not sealed with an appropriate firestop material. Interview with the environmental services supervisor at the time of the observation confirmed that finding. He stated the conduit installations had been done at the time of the nursing home construction in 2014.

The deficiency affected one of three smoke compartments.

Based on observation and interview, the provider failed to maintain the required exit corridor width at the south end of the patient wing (day room area). Findings include:

1. Observation at 3:15 p.m. on 4/12/16 revealed the day room area (south end of the patient wing) was located in the exit corridor. The corridor area had multiple benches, tables, and chairs which restricted the corridor width from the required eight feet to just 30 inches. Interview with the administrator at the time of the observation confirmed that finding.

The deficiency has the potential to affect egress exit ability for all occupants of that smoke compartment.

A. Based on observation, testing and interview, the provider failed to maintain the battery pack emergency light for the generator transfer switch at one of two locations (electrical room 614). Findings include:

1. Observation at 1:45 p.m. on 4/12/16 revealed electrical room E614 had a transfer switch located in the room. There was a battery pack emergency light located in the room. Testing of that emergency light at the time of the observation revealed the lamps did not function. Interview with the envionmental services supervisor at the time of the observation confirmed that finding. He added that light was not yet on his preventive maintance list.

The deficiency affected one of numerous requirements for generator installations.

Based on observation and interview, the provider failed to install a battery pack emergency light for the generator transfer switch in electrical room E613. Findings include:

2. Observation at 2:15 p.m. on 4/12/16 revealed there was a generator transfer switch located in electrical room E613. There was not a battery pack emergency light located in that room. Interview with the environmental services supervisor at 2:00 p.m. on 4/12/16 indicated he was unaware of the requirement for the emergency lighting at the transfer switch location.

The deficiency affected one of numerous requirements for generator installations.

B. Based on interview and document review, the provider failed to conduct five minute cool-down periods following the required thirty minute monthly emergency generator load tests for 2015. Findings include:

1. Interview with the environmental services supervisor at 2:45 p.m. on 4/12/16 revealed the emergency generator was exercised weekly with a load test performed once per month. Review of the generator log (hour meter readings) revealed the load test runs were performed for a period of thirty minutes. A five minute cool-down run time is required after the thirty minute load run. Interview with the environmental services supervisor at 3:00 p.m. on 4/12/16 indicated he was unaware of the requirement for the five minute cool-down period following the full load test.

The deficiency had the potential to affect 100% of the building occupants.

Based on observation and interview, the provider failed to maintain a 36 inch clear depth of working space in front of three of three electrical panels (in the clean utility room). Findings include:

1. Observation at 1:45 p.m. on 4/12/16 revealed electrical panels LCBC, LNC, and LEQC in the clean utility room had three carts placed directly in front of them. There were no markings on the floor to show the depth of space required to be kept clear for the electrical panels. Interview with the environmental services supervisor at the time of the observation confirmed that condition. He stated staff assumed since the shelving/carts were on wheels, the depth of working space requirement did not have to be maintained.

The deficiency affected one of numerous requirements for electrical installations.