HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure that exit discharge was maintained free of obstruction in accordance with NFPA (National Fire Protection Association) 96. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Observation on 04/15/25 at approximately 1:51 p.m., revealed the exit discharge from the rear Laboratory area did not discharge to a refuge area or public way, as this exit discharged into a covered breezeway leading to a storage building.

Interview on 04/15/25 at approximately 1:52 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.

Based on observation and staff interview, the facility failed to ensure that hazardous areas are protected and separated from other spaces in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Observation on 04/15/25 at approximately 10:55 a.m., revealed missing ceiling tile and unsealed penetrations in the drop ceiling in the IT Server Room and the Maintenance Technician Office in the Mechanical/Boiler Room.

Observation on 04/15/25 at approximately 1:54 p.m., revealed the Lab Storage Room near Respiratory Therapy, which was being used as a storage room with combustible storage and measured more than 50 square feet, did not have a door closure.

Observation on 04/15/25 at approximately 2:06 p.m., revealed the Housekeeping Clean Utility Room near Speech Therapy, which was being used as a storage room with combustible storage and measured more than 50 square feet, did not have a door closure.

Interview on 04/15/25 at approximately 2:07 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.

Based on record review and staff interview, the facility failed to properly install and maintain equipment protected by the kitchen hood extinguishing system in accordance with NFPA (National Fire Protection Association) 96. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Record review on 04/14/24 at approximately 12:55 p.m., revealed no documentation available for review during survey to show that the kitchen suppression system had received hydrostatic testing in the previous twelve (12) years.

Interview on 04/14/25 at approximately 12:56 p.m. with the Facilities Manager verified this finding. This finding was also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.

Based on observation and staff interview, the facility failed to ensure that the automatic sprinkler system was tested and maintained in accordance with NFPA (National Fire Protection Association) 25. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Observation on 04/15/25 at approximately 10:06 a.m., revealed communication wiring laying on the sprinkler system in the interstitial space above the corridor near Physical Therapy.

Observation on 04/15/25 at approximately 10:47 a.m., revealed communication wiring laying on the sprinkler system in the interstitial space above Speech Therapy and the Virtual Pharmacy Office.

Observation on 04/15/25 at approximately 11:05 a.m., revealed communication wiring laying on the sprinkler system throughout the interstitial space above the X-Ray/Maintenance Corridor and near the DEXA Room area.

Observation on 04/15/25 at approximately 11:20 a.m., revealed water supplies lines being supported by a wooden wedge, which was placed on the sprinkler system in the interstitial space above the Main Lobby area.

Interview on 04/15/25 at approximately 11:21 a.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.

Based on observation and staff interview, the facility failed to ensure that fire barriers and smoke barriers were constructed and maintained in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Observation on 04/15/25 at approximately 10:27 a.m., revealed an unsealed penetration in the 2-hour fire barrier, in the interstitial space above the ceiling near the Acute Care fire barrier doors.

Observation on 04/15/25 at approximately 10:29 a.m., revealed an unsealed penetration in the 2-hour fire barrier, in the interstitial space above the ceiling near the Storage Room Wall in the Purchasing Corridor.

Observation on 04/15/25 at approximately 10:38 a.m., revealed unsealed penetrations in the 2-hour fire barrier, in the interstitial space above the ceiling near the Virtual Pharmacy Office.

Observation on 04/15/25 at approximately 10:57 a.m., revealed the Mechanical/Boiler Room (2-hour fire barrier) door was sagging and bowed at the top and exceeded the the 1/8-inch requirement at the meeting edges along the top and sides of the door.

Observation on 04/15/25 at approximately 12:22 p.m., revealed a set of 2-hour rated fire barrier doors at the entrance to the Long Term Care Unit (2-hour fire barrier), which had the bottom rods and latches removed/missing and did not appear to have fire pins in the bottom of the doors.

Observation on 04/15/25 at approximately 1:42 p.m., revealed the 2-hour rated fire barrier doors in the Maintenance Corridor near the Mechanical Room would not close and latch when released.

Observation on 04/15/25 at approximately 1:45 p.m., revealed the 2-hour rated fire barrier doors in the X-Ray/Maintenance Corridor near the Financial Counselor Office would not close and latch when released.

Interview on 04/15/25 at approximately 1:46 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.

Based on observation and staff interview, the facility failed to ensure that electrical wiring and equipment was in accordance with NFPA (National Fire Protection Association) 70. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Observation on 04/15/25 at approximately 11:02 a.m., revealed a heating, ventilation, and air conditioning (HVAC) control box missing an appropriate cover in the interstitial space above the X-Ray/Maintenance Corridor near the DEXA Room.

Observation on 04/15/25 at approximately 12:44 p.m., revealed a microwave plugged into an extension cord in the Doctor's Sleep Room.

Observation on 04/15/25 at approximately 1:22 p.m., revealed a power strip plugged into a second power strip in the Emergency Room Physician's Office.

Observation on 04/15/25 at approximately 1:24 p.m., revealed a refrigerator plugged into a power strip in the Emergency Room Nurse's Station (hand sink area).

Observation on 04/15/25 at approximately 1:29 p.m., revealed three (3) coffee pots plugged into a power strip in the Emergency Room Break Room.

Interview on 04/15/25 at approximately 1:30 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.

Based on observation, record review, and staff interview, the facility failed to ensure that portable space heaters were used in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Observation on 04/15/25 at approximately 12:29 p.m., revealed a portable space heater in use in the Risk Management Office. No documentation was provided during survey to show that the elements in this space heater did not exceed 212 degrees Fahrenheit.

Observation on 04/15/25 at approximately 12:33 p.m., revealed a portable space heater in use in the Director of Nursing Office. No documentation was provided during survey to show that the elements in this space heater did not exceed 212 degrees Fahrenheit.

Observation on 04/15/25 at approximately 12:43 p.m., revealed a portable space heater in use in the Doctor's Sleep Room. No documentation was provided during survey to show that the elements in this space heater did not exceed 212 degrees Fahrenheit.

Observation on 04/15/25 at approximately 1:06 p.m., revealed a portable space heater in use in the Patient Access Coordinator's Office. No documentation was provided during survey to show that the elements in this space heater did not exceed 212 degrees Fahrenheit.

Observation on 04/15/25 at approximately 1:21 p.m., revealed two (2) portable space heaters in use in the Emergency Room Physician's Office. No documentation was provided during survey to show that the elements in these space heaters did not exceed 212 degrees Fahrenheit.

Observation on 04/15/25 at approximately 1:25 p.m., revealed a portable space heater in use in the Emergency Room Nurse's Station area. No documentation was provided during survey to show that the elements in this space heater did not exceed 212 degrees Fahrenheit.

Interview on 04/15/25 at approximately 1:26 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.

Based on observation, record review, and staff interview, the facility failed to ensure that the emergency generator was tested and maintained in accordance with NFPA (National Fire Protection Association) 110. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Record review on 04/14/25 at approximately 12:51 p.m., revealed no documentation available for review during survey to show that an annual fuel quality test for the emergency generator had been completed in the previous twelve (12) months.

Record review on 04/14/25 at approximately 1:13 p.m., revealed no documentation available for review during survey to show that emergency generator had been exercised with the available load monthly during March 2025, January 2025, August 2024, June 2024, or May 2024. A load bank test had not been completed in the previous twelve (12) months.

Interview on 04/15/25 at approximately 1:14 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.

Based on observation and staff interview, the facility failed to ensure that oxygen cylinders were stored and maintained in accordance with NFPA (National Fire Protection Association) 99. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Observation on 04/15/25 at approximately 12:47 p.m., revealed empty and full oxygen E-cylinders, which were not properly segregated in the Acute Care Storage Room, near Purchasing.

Observation on 04/15/25 at approximately 12:48 p.m., revealed oxygen E-cylinders, which were stored less than five (5) feet from combustibles in the Acute Care Storage Room, near Purchasing.

Observation on 04/15/25 at approximately 1:32 p.m., revealed the Emergency Room Utility Room, which was being used to store oxygen E-cylinders, did not have a precautionary sign readable from five (5) feet of the door, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING".

Observation on 04/15/25 at approximately 1:59 p.m., revealed an unsecured gas cylinder (therapy treatment gas) in the Pulmonary Function Room in Respiratory Therapy.

Observation on 04/15/25 at approximately 2:00 p.m., revealed the Pulmonary Function Room in Respiratory Therapy, which was being used to stored oxygen E-cylinders, did not have a precautionary sign readable from five (5) feet of the door, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING".

Interview on 04/15/25 at approximately 2:01 p.m. with the Facilities Manager verified these findings. These findings were also acknowledged by the Chief Executive Officer at the exit interview on 04/15/25 at approximately 5:43 p.m.