HospitalInspections.org

Based on an observation made of the facility during the survey on 06/21/2022, it was observed and noted that the room by back storage is being used as storage. If storage is to exist in that room , that room must have a 1-hour rated wall 360 degrees around the room, and a application must be submitted to the office of ARU in order for that to proceed.





Also based on an observation made of the facility during the survey on 06/21/2022, it was observed and noted that the office next to room 127 is being used as storage. If storage is to exist in that room , that room must have a 1-hour rated wall 360 degrees around the room, and a application must be submitted to the office of ARU in order for that to proceed.





Also based on an observation made of the facility during the survey on 06/21/2022, it was also observed and noted that ICU room 5 is being used as offices. If this room is to continue as offices, then all patient services must be removed from the room. And this includes capping the medical gases, removing the nurse call, and also submitting an application to the office of ARU in order for the project to proceed.





Also based on an observation made of the facility during the survey on 06/21/2022, it was observed and noted that the narcotics room is being used as storage. If storage is to exist in that room , that room must have a 1-hour rated wall 360 degrees around the room, and a application must be submitted to the office of ARU in order for that to proceed.





Also based on an observation made of the facility during the survey on 06/21/2022, it was observed and noted that the IT closet in the med surge area is also being used as storage. If storage is to exist in that room , that room must have a 1-hour rated wall 360 degrees around the room, and a application must be submitted to the office of ARU in order for that to proceed.



Also based on an observation made of the facility during the survey on 06/21/2022, it was observed and noted that the staff only restroom has a nurse call pull cord in it. Based on interviews with the staff members, this room use to be a patient restroom. Because it is now a staff restroom the nurse call pull cord system must be removed.

Based on an observation made of the facility during the survey on 06/21/2022, it was observed and noted that the exit light at the patient room in ICU is burned out.

Based on an observation made of the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility does not have any current or previous reports from testing and inspecting there kitchen hood system semi-annually on site.

Based on an observation made of the facility during testing of the fire alarm system on 06/21/2022, it was observed and noted that the ICU hallway has no audible visual fire alarm devices in that hallway. During fire alarm testing, it was very difficult in that hallway to hear any type of fire alarms going off during testing.

Based on an observation made of the paperwork provided during the survey on 06/21/2022, it was observed and noted that the fire alarm is not being tested at the correct intervals. The fire alarm system is only being tested annually, it is not being tested quarterly as required.




Also based on an observation made of the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is missing the paperwork on all 4 fire alarm inspections for 2020.





Also based on an observation made of the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is missing the paperwork on all 4 fire alarm inspections for 2021.




Also based on an observation made of the paperwork provided, it was observed and noted that both quarterly fire alarm inspection reports are missing from 2022.

Based on an observation made of the facility during the survey on 06/21/2022, it was observed and noted that the facility only has a partial limited sprinkler system. This in not a deficiency based on the NFPA 101 code,chapter 19 existing facilities but based on observations made of the facility it is a concern that several hazard areas that need fire sprinkler protection do not have it.

Based on an observation made of the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is not testing and inspecting their fire sprinkler system at the correct intervals. The fire sprinkler system is only being tested annually, rather than the required inspections taking place quarterly.






Also based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is missing all fire sprinkler annual and quarterly sprinkler inspection reports from 2020.






Also based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is missing all fire sprinkler annual and quarterly sprinkler inspection reports from 2021.





Also based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is missing the first quarter fire sprinkler inspection reports from 2022.

Based on an observation made of the paperwork provided during the survey on 06/21/2022, it was observed and noted that the annual fire extinguisher inspection reports from 2020 and 2021 are missing.

Based on an observation made of the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is not doing annual receptacle testing.

Based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is not performing the fire drills at the correct intervals. The facility is not doing 1 fire drill per shift per quarter.






Also based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that all fire drill report logs were missing from 2020.






Also based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that all fire drill report logs were missing from 2021.






Also based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that all fire drill report logs were missing from 2022.

Based on an observation made during the walk through of the facility on 06/21/2022, it was observed and noted that several patient room privacy curtains did not have the required NFPA-701 flame retardant documented tag on them.

Based on an observation made of the paperwork provided during the survey on 06/21/2022, it was observed and noted that the emergency generator is not being tested and inspected at the correct intervals. The generator should be inspected weekly, monthly and also a annual load bank test.






Also based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is missing 3 weeks of the weekly generator logs from January 2020.




Also based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is missing 1 weeks the weekly generator logs from October 2020.






Also based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is missing 3 weeks of the weekly generator logs from December 2020.






Also based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that the annual 4- hour load bank test reports were missing from 2020 and 2021.






Also based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is missing 1 week of the weekly generator logs from April 2022.









Also based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is missing all weeks of the weekly generator logs from March 2022.






Also based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is missing all weeks of the weekly generator logs from January 2022.











Also based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is missing all weeks of the weekly generator logs from February 2022.








Also based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is missing all weeks of the weekly generator logs from January 2021.






Also based on the paperwork provided during the survey on 06/21/2022, it was observed and noted that the facility is missing all weeks of the weekly generator logs from February 2021.