HospitalInspections.org

Based on record review and interview, the provider failed to conduct an exercise for emergency preparedness in 2023. Findings include:

1. Record review on 6/4/24 at 4:45 p.m. revealed no documentation an exercise was conducted to test the emergency plan for 2023.

Interview with the plant operations manager on 6/5/24 at 7:30 a.m. and the ambulance supervisor on 6/5/24 at 6:57 p.m. confirmed that finding.

Based on observation, interview, and document review, the provider failed to meet the minimum construction standards of the 2012 Life Safety Code (LSC) (incomplete NFPA 13 sprinkler system installation). Findings include:

1. Observation on 6/4/24 at 9:25 a.m. revealed the building was a three-story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system. Interview with the plant operations director at the time of the observation confirmed that finding.

Review of previous survey documents dated 7/8/19 confirmed the above condition.

The facility meets the fire safety evaluation system (FSES). Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation, interview, and document review, the provider failed to maintain conforming exit stairways in five randomly observed locations (south stairs, northwest stairs, east stairs, west stairs, and the north stairs). Findings include:

1. Observation on 6/4/24 at 11:15 a.m. revealed handrails were not provided on both sides of the stairwell in the south stairs and at the top of the landing of the northwest stairs. The south stairs were 39 inches wide. The northwest stairs were 50 inches wide.

2. Observation on 6/4/24 at 2:30 p.m. revealed the interior landing in front of the exterior exit door in the south stairs sloped up approximately six inches to the door threshold.

3. Observation on 6/4/24 between 2:30 p.m. and 3:00 p.m. revealed the following door openings into stair enclosures reduced the landing widths to less than 22 inches:
* The door opening into the first floor, east stairs reduced the landing to 15 inches.
* The door opening into the first floor, west stairs reduced the landing to 19 inches.
* The door opening into the first floor, north stairs reduced the landing to 17 1/2 inches.

4. Interview with the director of plant operations at the time of the above observations confirmed those findings. Review of previous survey documents dated 7/8/19 confirmed the above findings.

The facility meets the fire safety evaluation system (FSES). Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to install exit signs for one of one exit locations in the connecting link from the hospital to the clinic. The connecting link exterior door was also magnetically locked. Findings include:

1. Observation on 6/4/24 at 9:45 a.m. revealed an exterior door from the connecting link for the hospital to the clinic. There was no marked exit for the connecting link. The exterior door was also magnetically locked without a delayed egress feature or access-controlled feature to exit the connecting link.

Interview with the plant operations manager at the time of the observation confirmed those findings.

The deficiency affected one location required to be provided with a marked and identifiable path of egress.

Based on record review and interview, the provider failed to conduct the required every six-month inspection of the facility's cooking ductwork exhaust system for the range hood for calendar year 2023. Findings include:

1. Record review revealed there was no documentation the kitchen hood exhaust ductwork had been inspected for cleanliness and grease build-up in 2023.

Interview with the plant operations manager on 6/4/24 at 1:00 p.m. revealed he was unaware of the ductwork inspection requirements.

The deficiency affected the requirements for the kitchen range hood and exhaust system.

Based on observation, interview, and document review, the provider failed to meet the minimum construction standards of the 2012 Life Safety Code (LSC) (incomplete NFPA 13 sprinkler system installation). Findings include:

1. Observation on 6/4/24 at 12:45 p.m. revealed the building was a three-story, protected, non-combustible, Type II (111) structure without a complete automatic sprinkler system.

Interview with the plant operations director at the time of the observation confirmed that finding.

Review of previous survey documents dated 7/18/19 confirmed the above findings.

The facility meets the fire safety evaluation system (FSES). Please mark an "F" in the completion date column to indicate the facility's intent to correct the deficiencies identified in K000.

Based on observation and interview, the provider failed to maintain impediment-free closing for one randomly observed corridor door (library on the second floor) as required. Findings include:

1. Observation on 6/4/24 at 9:30 a.m. revealed the corridor door to the library on the second floor was held open with a chair. The chair could prevent the door from being closed in the event of a fire emergency.

Interview with the plant operations manager at the time of the observation confirmed that finding.

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