HospitalInspections.org

Based on visual observation the facility failed to provide corridor doors that were not closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room ' s occupants. The deficient practice had the potential to affect 14 of 14 residents.

Findings:

During the facility tour on 4/27 - 5/1/2018, between the hours of 8:30a-3:00p observation revealed the doors to the private dressing room, cafeteria & vending would not latch in the frame.

Interview with Administrator revealed the facility was not aware of the doors to these rooms were not latching in the frame.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 14 of 14 residents.
4 of 4 quarters in 2017-2018 were deficient.

Findings:

During the record review on 4/27 - 5/1/2018, between the hours of 8:30a-3:00p record review revealed 3 fire drills were conducted over the past 12 months.

Interview with Administrator revealed the facility was not aware fire drills were not being held for each shift per quarter.

Based on visual observation the facility failed to assure that the gas and vacuum piped system was inspected and tested in accordance with the requirements of NFPA 99. Activation of the system will provide needed oxygen to patients, which results in protection of life. This deficiency has the potential to affect 14 of 14 residents.

Findings:

During the facility tour on 4/27 - 5/1/2018, between the hours of 8:30a-3:00p observation revealed the gas And vacuum system was last inspected in March of 2016.

Interview with Administrator revealed the facility was not aware that the annual inspections had not been conducted on the gas and vacuum piped system.

Based on visual observation and record review, the facility failed to assure that the monthly testing program on the emergency generator was conducted and documented. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 14 of 14 residents.
12 of 12 months were deficient.

Findings:

During the record review on 4/27 - 5/1/2018, between the hours of 8:30a-3:00p record review revealed the emergency generator was not being exercised under load 30 minutes 12 times a year.

Interview with Administrator revealed the facility was not aware that all testing and documentation was not complete regarding the inspection/testing of the emergency generator.