HospitalInspections.org

Based on observation and staff interview, the facility failed to maintain hazardous storage room doors per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.2.1, 19.3.2.1.3, and 8.7.1.1. This deficient finding could have an widespread impact on the patients within the facility.

Findings include:

On 05/22/2024 at 11:30 AM, it was revealed by observation patient room 113 has been converted into combustible storage and did not have door closers and was not labeled as storage.

An interview with the Maintenance Tech verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, sections 5.2.1.1.1, 5.2.1.2 and 5.3.2.1. These deficient findings could have a patterened impact on the patients within the facility.

Findings include:

1. On 05/22/2024 at 12:00 PM, it was revealed by observation dust covered sprinkler heads in the therapy treatment rooms.

2. On 05/22/2024 at 12:10 PM, it was revealed by observation dust covered sprinkler head in the walk in cooler.

3. On 05/22/2024 at 12:10 PM, it was revealed by observation storage of boxes in the freezer were stored within 18" of a sprinkler head.


An interview with the Maintenance Tech verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to inspect fire doors per NFPA 101 (2012 edition), Life Safety Code section 8.3.3.1, and NFPA 80 (2010 edition), Standard for Fire Doors and Other Opening Protectives, section 5.2.1. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 05/22/2024 at 09:40 AM, it was revealed by a review of available documentation at the time of the survey the facility could not provide an annual fire door inspection report.

An interview with the Maintenance Tech verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to provide a Risk Assessment per NFPA 99 (2012 edition), Health Care Facilities Code, section 4.2. This deficient finding could have a widespread impact on the patients within the facility.

Findings include:

On 05/22/2024 at 09:50 AM, it was revealed by a review of available documentation that the facility could not provide a NFPA 99 Risk Assessment at the time of the survey.

An interview with the Maintenance Tech verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to maintain generators per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.3, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, sections 4.2, 8.4.9, 8.4.9.1 and 8.4.9.2. This deficient finding could have a widespread impact on the patients within the facility.

Findings include:

On 05/22/2024 at 10:20 AM, it was revealed by a review of available documentation that the facility failed to provide documentation of a 36-Month 4-hour generator load bank test.

An interview with the Maintenance Tech verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to maintain storage of an oxygen tank per NFPA 99 (2012 edition), Health Care Facilities Code, 11.6.2.3 (11). This deficient finding could have an isolated impact on the patients within the facility.

Findings include:

On 05/22/2024 at 1:24 PM, it was revealed by observation in oxygen storage room there were 3 oxygen tanks were not secured for tip resistance.

An interview with the Maintenance Tech verified this deficient finding at the time of discovery.