HospitalInspections.org

Based on a review of available documentation and staff interview, the facility failed to test and inspect the fire alarm system per NFPA 101 (2012 edition), Life Safety Code, section 9.6.1.3, and NFPA 72 (2010 edition), National Fire Alarm and Signaling Code, section 14.4.5. This deficient finding could have a widespread impact on residents within the facility.

Findings include:

On 06/04/2024 between 9:15 and 11:45 AM, it was revealed by a review of available documentation that the fire alarm system was overdue for an annual inspection. The last annual inspection occurred on 05/24/2023.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, sections 5.2.1.1, and 5.4.1.4.2. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

1. On 06/04/2024 between 9:15 and 11:45 AM, it was revealed by observation that an escutcheon plate was missing from a sprinkler head in the hallway by the Acillary Services Manager Office. Violation was corrected at the time of discovery.

2. On 06/04/2024 between 9:15 and 11:45 AM, it was revealed by observation that several sprinkler heads were being stored unsecured in the sprinkler cabinet in the sprinkler riser room.

An interview with the Executive Director and Maintenance Director verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to conduct fire drills per NFPA 101 (2012 edition), Life Safety Code section 19.7.1.6. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 06/04/2024 between 9:15 and 11:45 AM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing that fire drills were conducted during the second shift of the first quarter of 2024, and the 3rd and 4th quarter of 2023. Drills were also not conducted on the 3rd shift during the second quarter of 2023.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to provide a Risk Assessment per NFPA 99 (2012 edition), Health Care Facilities Code, section 4.2. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 06/04/2024 between 9:15 and 11:45 AM, it was revealed by a review of available documentation that the facility could not provide a NFPA 99 Risk Assessment for Chapters 5, 6, 9, 10 and 11 at the time of the survey.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to maintain the emergency generator per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.3, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, sections 8.4.9, 8.4.9.1, 8.4.9.2, and 8.4.9.7. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 06/04/2024 between 9:15 and 11:45 AM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing a four (4) hour load bank test has been completed within the last 36 months for the 250 kw diesel generator.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.