HospitalInspections.org

E-0004
Based on review of the Jenkins County Medical Facility's Emergency Preparedness Plan and interviews with staff it was determined that the facilities plan was not in substantial compliance set forth in Appendix Z.
This could place 2 residents and or staff at risk in the event of a disaster emergency.
The findings include:
During a review of the facilities Emergency Preparedness Plan on 05/21/2018 between 08:30 am and 3:00 pm it was noted that this facility has not completed the required all hazards approach. Facility did not address all immediate local hazards to this facility. Facility did not meet the requirements of Appendix Z.
These findings were confirmed by Staff M at the time of discovery.

E-0009
Based on review of the Jenkins County Medical Facility's Emergency Preparedness Plan and interviews with staff it was determined that the facilities plan was not in substantial compliance set forth in Appendix Z.
This could place 2 residents and or staff at risk in the event of a disaster emergency.
The findings include:
During a review of the facilities Emergency Preparedness Plan on 05/21/2018 between 08:30 am and 3:00 pm it was noted that this facility has not reached out to local EMA officials for assistance and approval of emergency preparedness plans in place. Facility did not meet the requirements of Appendix Z.
These findings were confirmed by Staff M at the time of discovery.

E-0025
Based on review of the Jenkins County Medical Facility's Emergency Preparedness Plan and interviews with staff it was determined that the facilities plan was not in substantial compliance set forth in Appendix Z.
This could place 2 residents and or staff at risk in the event of a disaster emergency.
The findings include:
During a review of the facilities Emergency Preparedness Plan on 05/21/2018 between 08:30 am and 3:00 pm it was noted that this facility has provided documentation of signed contracts with other facilities and or suppliers for emergency needs during a disaster. Facility did not meet the requirements of Appendix Z.
These findings were confirmed by Staff M at the time of discovery.

K-291
Based on observation, and or review of facility records, and staff interviews it was determined the facility failed to
This could place 2 residents/patients and staff at risk in the event of a fire or other emergency.
The findings include:
During a tour of the facility with Staff M on 05/21/2018 between 08:30 am and 3:00 pm observation revealed the following:
1. No annual testing of emergency lights was produced during this survey
2. Emergency lights had no documentation of monthly testing.
3. Emergency lights had no documentation of yearly 90 minute testing.
4. Emergency light in kitchen does not work.
These findings were confirmed by Staff M at the time of discovery.
" Emergency Light Testing Reference: 2012 NFPA 101, 19.2.9.1 and 7.9.3.1.1
" Emergency Light Not Working Reference: 2012 NFPA 101, 19.2.9.1 and 7.9.2.1

K-311
Based on observation, and or review of facility records, and staff interviews it was determined the facility failed to maintain vertical penetrations.
This could place 2 residents/patients and staff at risk in the event of a fire or other emergency.
The findings include:
During a tour of the facility with Staff M on 05/21/2018 between 08:30 am and 3:00 pm observation revealed that a vertical penetration hole was in ceiling tile in emergency room hallway.
These findings were confirmed by Staff M at the time of discovery.
" Reference: NFPA 101, 2012 Edition, Chapter 19, Section 19.3.1

K-321
Based on observation, and or review of facility records, and staff interviews it was determined the facility failed to maintain door closer's.
This could place 2 residents/patients and staff at risk in the event of a fire or other emergency.
The findings include:
During a tour of the facility with Staff M on 05/21/2018 between 08:30 am and 3:00 pm observation revealed that the exit door closer was missing from door leaving out of lab into egress hallway.
These findings were confirmed by Staff M at the time of discovery.
" Reference: 2012 NFPA 101, 19.3.2.1.3

K-324
Based on observation, and or review of facility records, and staff interviews it was determined the facility failed to maintain kitchen hood cleaning.
This could place 2 residents/patients and staff at risk in the event of a fire or other emergency.
The findings include:
During a tour of the facility with Staff M on 05/21/2018 between 08:30 am and 3:00 pm observation revealed that kitchen hood system had no current documentation of cleaning.
These findings were confirmed by Staff M at the time of discovery.
" Reference: 2012 NFPA 101, 19.3.2.5.1 and 9.2.3, 2011 NFPA 96, 11.2

K-345
Based on observation, and or review of facility records, and staff interviews it was determined the facility failed to maintain fire alarm system(s).
This could place 2 residents/patients and staff at risk in the event of a fire or other emergency.
The findings include:
During a tour of the facility with Staff M on 05/21/2018 between 08:30 am and 3:00 pm observation revealed that no annual fire alarm testing certification papers were available at time of inspection.
These findings were confirmed by Staff M at the time of discovery.
" Reference: NFPA 101, 2012 Edition, Chapter 19, Section, 19.3.4.1, Chapter 9, Section, 9.6.1, 9.6.1.1, 9.6.1.5, 2010 NFPA 72 Chapter 14, Section 14.1.1,14.2, 14.4

K-351
Based on observation, and or review of facility records, and staff interviews it was determined the facility failed to mark PIV valve.
This could place 2 residents/patients and staff at risk in the event of a fire or other emergency.
The findings include:
During a tour of the facility with Staff M on 05/21/2018 between 08:30 am and 3:00 pm observation revealed that no signage was place on PIV (post indicator valve) located at street to indicate its location and what building it serves.
These findings were confirmed by Staff M at the time of discovery.
" Reference: 2012 NFPA 101, Chapter 19, section 19.3.5.1, Chapter 9, section 9.7.5, Chapter 2, section 2.2, 2011 NFPA 25, section 4.1.8, 4.1.8.1, 4.1.8.2

K-353
Based on observation, and or review of facility records, and staff interviews it was determined the facility failed to maintain fire sprinkler system(s) and or its components.
This could place 2 residents/patients and staff at risk in the event of a fire or other emergency.
The findings include:
During a tour of the facility with Staff M on 05/21/2018 between 08:30 am and 3:00 pm observation revealed the following:
1. No documentation at time of inspection of annual fire sprinkler system testing certification.
2. Painted fire sprinkler head in x-ray room.
3. Shelving storage exceeds height limit in Physical Therapy storage room.
4. Loaded fire sprinkler heads in public restroom on 100 hall and room 117.
5. Fire Sprinkler room has no signage to indicate location of fire sprinkler system.
6. No 5 year internal sprinkler riser inspection documentation was available at inspection.
7. FDC (fire department connections) at street requires a sign to indicate FDC location and what building(s) it serves.
8. No documentation of backflow testing of fire sprinkler riser system.
These findings were confirmed by Staff M at the time of discovery.
" Annual Inspection Reference: 2012 NFPA 101, Chapter 19, Section 19.3.5.1, Chapter 9, Section 9.7.5, 9.7.7, 9.7.8; 2011 NFPA 25, 4.1.4.1, 4.5.1, 5.1.1.2
" Painted Heads Reference: 2012 NFPA 101, 4.6.12.1, NFPA 25 2011 edition: Chapter 5, Section 5.2.1.1.2 (5), & (6), & Chapter 5, Section 5.2.1.1.4
" Storage Height Reference: NFPA 101, 2012 ED. Chapter 19, Section 19.3.5.1, Chapter 9, sections: 9.7.1.1.(1), NFPA 13, 2010 Edition, Chapter 8, Section 8.5.6 & 8.5.6.1
" Loaded Sprinkler Head Reference: NFPA 101 2012: Chapter 19 Section 19.3.5.1, Chapter 9, Section 9.7.5, NFPA 25, 2011 edition: Chapter 5, Section 5.2.1.1.2 (5), & (6), & Chapter 5, Section 5.2.1.1.4
" No Annual Inspection Documentation Reference: 2012 NFPA 101 Chapter 19, Section 19.3.5.1, Chapter 9, Section 9.7.5, 9.7.7, 9.7.8; 2011 NFPA 25, 4.1.4.1, 4.5.1, 5.1.1.2
" 5 Year Internal Reference: NFPA 101 2012 ED. CHAPTER 19, SECTION 19.3.5.1 and CHAPTER 9, SECTION 9.7.5, 9.7.7, & 9.7.8, 2011 NFPA 25, 14.2.1
" FDC Signage Reference: NFPA 101, 2012 Edition, 19.3.5.1, 9.7, 9.7.1, 9.7.1.1, NFPA 13, 2010 Edition, Chapter 8, Section 8.17.2.4.5.
" Back Flow Reference: 2012 NFPA 101, Chapter 19, Section 19.3.5.1, Chapter 9, Section 9.7.5, 2011 NFPA 25, Chapter 13, Section 13.6.2.1

K-363
Based on observation, and or review of facility records, and staff interviews it was determined the facility failed to maintain doors.
This could place 2 residents/patients and staff at risk in the event of a fire or other emergency.
The findings include:
During a tour of the facility with Staff M on 05/21/2018 between 08:30 am and 3:00 pm observation revealed the following:
1. Kitchen door not latching secure
2. Storage room door from Physical Therapy room.
3. Egress door from nursing floor to main lobby chocked open against closer and will not close.
4. Door 137 does not close secure.
These findings were confirmed by Staff M at the time of discovery.
" Reference: 2012 NFPA 101 Chapter 19 sections 19.3.7.6, 19.3.7.8; Chapter 8 sections 8.5.4.3

K-372
Based on observation, and or review of facility records, and staff interviews it was determined the facility failed to maintain fire walls.
This could place 2 residents/patients and staff at risk in the event of a fire or other emergency.
The findings include:
During a tour of the facility with Staff M on 05/21/2018 between 08:30 am and 3:00 pm observation revealed that fire walls are not sealed with proper fire sealants. This is to include all fire walls in building.
These findings were confirmed by Staff M at the time of discovery.
" Reference: 2012 NFPA 101 Chapter 19, Section 19.3.7.3; Chapter 8, Sections 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2, 8.5.6.3 and Chapter 4, Section 4.6.12.1

K-511
Based on observation, and or review of facility records, and staff interviews it was determined the facility failed to maintain electrical systems and appliances.
This could place 2 residents/patients and staff at risk in the event of a fire or other emergency.
The findings include:
During a tour of the facility with Staff M on 05/21/2018 between 08:30 am and 3:00 pm observation revealed the following:
1. Electric space heaters found in emergency room office, x-ray office & doctors lounge/bedroom.
2. Electrical panel EB missing breaker in panel and has open void.
These findings were confirmed by Staff M at the time of discovery.
" Space Heater Reference: NFPA 101, 2012 Edition, Chapter 19, Section 19.7.8
" Open Void Reference: NFPA LSC, 2012 Edition: Chapter 19, 19.5.1.1, Chapter 9, 9.1.2, 2011 NFPA 70, Article 408.7

K-712
Based on observation, and or review of facility records, and staff interviews it was determined the facility failed to maintain fire drill records.
This could place 2 residents/patients and staff at risk in the event of a fire or other emergency.
The findings include:
During a tour of the facility with Staff M on 05/21/2018 between 08:30 am and 3:00 pm observation revealed that fire drill documentation could not be produced after 2016.
These findings were confirmed by Staff M at the time of discovery.
" Reference: 2012 NFPA 101, 19.7.1.4 through 19.7.1.7

K-916
Based on observation, and or review of facility records, and staff interviews it was determined the facility failed to provide remote annunciator.
This could place 2 residents/patients and staff at risk in the event of a fire or other emergency.
The findings include:
During a tour of the facility with Staff M on 05/21/2018 between 08:30 am and 3:00 pm observation revealed that no remote annunciator for the generator was installed in building in a constantly monitored location.
These findings were confirmed by Staff M at the time of discovery.
" Reference: 2012 NFPA 99 Chapter 6 section 6.4.1.1.17

K-920
Based on observation, and or review of facility records, and staff interviews it was determined the facility failed to maintain electrical cord and appliances.
This could place 2 residents/patients and staff at risk in the event of a fire or other emergency.
The findings include:
During a tour of the facility with Staff M on 05/21/2018 between 08:30 am and 3:00 pm observation revealed the following:
1. Extension cord in use as permanent wiring in kitchen.
2. Power strip on floor of kitchen office.
These findings were confirmed by Staff M at the time of discovery.
" Extension Cord Reference: 2012 NFPA 99, Chapter 10, section 10.2.4, 10.2.3.6, 2011 NFPA 70, Chapter 400, section 400.8, 590.3(D)
" Power Strip Reference: NFPA 99, 2012 edition Chapter 10, section 10.4.2.1 through 10.4.2.3 and S&C letter 14-46-LSC

K-923
Based on observation, and or review of facility records, and staff interviews it was determined the facility failed to maintain 02 cylinders and signage on 02 storage room door.
This could place 2 residents/patients and staff at risk in the event of a fire or other emergency.
The findings include:
During a tour of the facility with Staff M on 05/21/2018 between 08:30 am and 3:00 pm observation revealed the following:
1. Oxygen storage not marked empty/full in operating room suites and cardiology storage closet.
2. Oxygen storage rooms listed above are not marked with proper signage on exterior of doors.
These findings were confirmed by Staff M at the time of discovery.
" 02 Storage Reference: 2012 NFPA 101, 19.3.2.4, 8.7; 2012 NFPA 99, 11.6.5.302
" Storage Room Doors: 2012 NFPA 101 - 19.3.2.4, 8.7; 2012 NFPA 99 Ch. 11 section 11.3.4.1 and 11.3.4.2