HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of three floors.

Findings include:

1. Observation on October 30, 2024, at 12:39 p.m., revealed the 1st floor, Pharmacy Storage Room door was held open by unapproved means. (rubber door stop).


Exit interview with the Administrator and Maintenance Representative on October 30, 2024, at 1:00 p.m., confirmed the door being held open.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of nine smoke compartments.
Findings include:

1. Observation on October 30, 2024, at 11:55 a.m., Basement level, revealed the Central Kitchen, walk in freezer, had a sprinkler head that was displaced outside of the sprinkler escutcheon.

Exit interview with the Administrator and Maintenance Representative on October 30, 2024, at 1:00 p.m., confirmed the sprinkler head being displaced.

Based on observation and interview, it was determined the facility failed to maintain monthly inspection for eighteen of sixty-three portable fire extinguishers, affecting the entire facility.

Findings include:

1. Observation on October 30, 2024, between 11:30 a.m., and 12:45 p.m., revealed 18 portable fire extinguishers, in various areas throughout the facility, had pre-dated monthly inspections for November 2024, marked on the tag.



Exit interview with the Administrator and Maintenance Representative on October 30, 2024, at 1:00 p.m., confirmed the pre-dated inspections.

Based on document review and interview, it was determined the facility failed to maintain the emergency generator which serves the entire facility.

Findings include:

1. Observation on October 30, 2024, between 10:30 a.m., and 11:30 a.m., revealed the facility could not provide documentation for monthly testing, 30 minute run under load, battery electrolyte specific gravity or conductance test and operate transfer switches, being conducted within the last 12 months.

Exit interview with the Administrator and Maintenance Representative on October 30, 2024, at 1:00 p.m., confirmed the lack of documentation.

Based on observation and interview, it was determined the facility failed to maintain portable oxygen cylinder storage in one location, affecting one of nine smoke compartments.

Findings include:

1. Observation on October 30, 2024, at 11:46 a.m., Basement level, revealed 2 freestanding portable oxygen cylinders being stored in the medical gas storage room.

Exit interview with the Administrator and Maintenance Representative on October 30, 2024, at 1:00 p.m., confirmed the oxygen cylinders were not secured from falling over.