HospitalInspections.org

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Based on observation and interview, the facility failed to maintain the automatic fire-extinguishing system for cooking equipment per the requirements of:

2012 NFPA 101, 19.3.2.5.1 and 9.2.3
2011 NFPA 96, 10.2.6 (4)
2009 NFPA 17A, 7.2.2 (7)

Findings include:

On 12/12/2017, during a tour of the facility from 10:30 am to 3:30 pm, the surveyor observed that 3 out of the 5 nozzles for the automatic fire-extinguishing system under the kitchen hood were observed with their blowoff caps not intact.

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

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Based on observation and interview, the facility failed to install an alcohol-based hand-rub dispenser (ABHR) per requirements of:

2012 NFPA 101, 19.3.2.6 (8)

This deficiency could affect 15 residents.

Findings include:

On 12/12/2017, during a tour of the facility from 10:30 am to 3:30 pm, the surveyor observed that the ABHR in the Switchboard/Information Office was mounted directly above a light switch (ignition source).

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

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

2012 NFPA 101, 19.3.5.12
2012 NFPA 101, 9.7.4.1
2010 NFPA 10, 6.1.3.8.3

This deficiency could affect 20 residents.

Findings include:

On 12/12/2017, during a tour of the facility from 10:30 am to 3:30 pm, the surveyor observed a portable fire extinguisher sitting on the floor in the Phone Room next to Outpatient.

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

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

2012 NFPA 99, 6.3.2.1
2011 NFPA 70, 408.7

Findings include:

On 12/12/2017, during a tour of the facility from 10:30 am to 3:30 pm, the surveyor observed an unused opening in the electrical panel LP-K in the kitchen.

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

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Based on observation and interview, the facility failed to maintain the fuel for the emergency diesel generator per the requirements of:

2012 NFPA 99, 6.4.4.1.1.3 and 6.5.4.2
2010 NFPA 110, 1.3, 8.3.8

Findings include:

On 12/12/2017, during a tour of the facility from 10:30 am to 3:30 pm, the facility failed to provide documentation on testing the fuel quality for the diesel generator within the past 12 months.

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

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Based on observation and interview, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.2.3 (11)

The deficiency could affect 16 residents.

On 12/12/2017, during a tour of the facility from 10:30 am to 3:30 pm, the surveyor observed unsecured oxygen cylinders in the following areas:
1. The Emergency Room
2. The Clean Utility Room by the Hopper

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

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Based on review of documentation and interview, the facility failed to provide documentation on the fire loss prevention in Operating Rooms per the requirements of:

2012 NFPA 99, 15.13

This deficiency could affect 10 residents.

Findings include:

On 12/13/2017, during a tour of the facility from 8:15 am to 11:00 am, the following was observed.

1. The facility failed to provide documentation on fire prevention/emergency procedures for operating room/surgical suite emergencies.
2. The facility failed to provide documentation for personnel on orientation and training for new operating room/surgical suite personnel, including physicians and surgeons on general safety practices for the area and specific safety practices for the equipment and procedures they will use.

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