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1307 CLEVELAND STREET

FRIONA, TX 79035

No Description Available

Tag No.: K0056

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Finance, Director of Quality & Risk Management, and Director of Maintenance it was observed that while it appears the facility had accomplished some yearly inspections required for the fire sprinkler system, the facility failed to provide a log indicating consistant and routine compliance of such.

Additionally, in the RADIOLOGY ROOM the following issues found were not in compliance:
Area of room near door to Corridor was missing a sprinkler head.
Area of room near X-ray Technician screen wall was also missing a sprinkler head.
The sprinkler head near the TOILET wall was not a minimum of 4 inches off the wall.

No Description Available

Tag No.: K0064

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Finance, Director of Quality & Risk Management, and Director of Maintenance it was observed that while it appears the facility had accomplished some yearly inspections required for all fire extinguishers, the facility failed to provide a comprehensive log indicating consistent and routine compliance of such.

No Description Available

Tag No.: K0130

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Finance, Director of Quality & Risk Management, and Director of Maintenance it was observed that the facility failed to provide a log indicating consistent, systematic compliance on the following issues and items:

1. Air filter change log.
2. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.

Additionally, the facility failed regarding the following:

3. MED GAS STORAGE has 2 electrical light switch locations less than 60 inches above finish floor.
4. Electrical panel LEL - LC2 mislabeled and LCS not included in label on LC3.
5. The following rooms had multiple electrical penetrations in the 1 hour fire-rated partitions that were not sealed as required:
EMERG. ELECTRICAL ROOM
MECH. ROOM
FIRE SPRINKLER STAND-PIPE ROOM
6. The EMERGENCY ELECTRICAL MAIN DISTRIBUTION PANEL was not separated by the required 1 hour fire-rated partition from the NORMAL ELECTRICAL ROOM which also contained the NORMAL ELECTRICAL MAIN DISTRIBUTION PANEL.
7. There were reserve Oxygen cylinders stored in the same room with the Vacuum Pump. This violates NFPA requirements.
8. The following cross-corridor door locations where magnetic hold-open devices occur had non-compliant issues:
NEAR ENDOSCOPY - Fire/Smoke doors did not close completely as required.
NEAR ADMINISTRATION - Fire/Smoke doors were not labeled.

No Description Available

Tag No.: K0144

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Finance, Director of Quality & Risk Management, and Director of Maintenance it was observed that the facility failed to provide an Emergency Generator log indicating consistent, systematic compliance on the required weekly inspections.