HospitalInspections.org

Based on observation, and staff interview, the facility failed to ensure that cooking equipment is protected in accordance with NFPA 96. This deficient practice could affect all residents, staff, and visitors. Facility census 9.
Findings include:


a) An observation on 1/7/25 at approximately 11:38 a.m., revealed a hood extingushing system without proper extingushing coverage over the griddle.

b) These findings were verified during an exit interview with the Maintenance Director, and CEO on 1/09/25 at 11:30 a.m.

Based on observation and staff interview, the facility failed to ensure that the facility was protected throughout by an approved automatic sprinkler system in accordance with NFPA (National Fire Protection Association) 13. This deficient practice could affect all residents, staff, and visitors. Facility census 9.

Findings include:

a) An observation on 1/7/25 at approximately 1:45 p.m.., revealed a sprinkler heads (3) in the Kitchen, near the dish area, that were corroded.

b) These findings were verified during an exit interview with the Maintenance Director,and CEO on 1/09/25 at 11:30 a.m.

Based on record review, observation, and staff interview between 1/7/25- 1/8/25 it was determined the facility failed to maintain electrical equipment within the facility. Facility census 9.

a) Observation on 1/7/25 revealed an appliance cord that served a kitchen freezer, spliced, with exposed wire connectors, to make the chord longer to reach a receptacle.

b) During record review on 1/08/25, findings revealed there was several failed damper tests with no corrective action for the following dampers:
i. ID- 08696
ii. ID- 08686

c) These findings were verified during an exit interview with the Maintenance Director, and CEO on 1/09/25 at 11:30 a.m.

Based on record review, and staff interview, the facility failed to maintain Fire Doors in accordance with NFPA (National Fire Protection Association) 101 and 80. This deficient practice could affect all residents, staff, and visitors. Facility census 9.

Findings include:

a) Record review on 1/8/25 at approximately 9:00 a.m. revealed the facility failed to ensure that the fire rated doors in Hosptial were inspected annually.

b)These findings were verified during an exit interview with the Maintenance Director, and CEO on 1/09/25 at 11:30 a.m.

Based on record review and staff interview, the facility failed to maintain and test electrical receptacles at patient bed locations in accordance with NFPA (National Fire Protection Association) 99. Facility census 9.

Findings include:

a) Record review on 1/8/25 at approximately 10:35 a.m.., revealed no current documentation for testing of the physical integrity, correct polarity, continuity of the grounding circuit, or retention force for each electrical receptacle at the patient bed locations in the facility.

b) These findings were verified during an exit interview with the Maintenance Director, and CEO on 1/09/25 at 11:30 a.m.