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Based on observation and staff interview, the facility failed to install self-closing device per NFPA 101 (2012 edition), Life Safety Code, section 19.3.2.1.3 and 19.3.2.1.5. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation that storage room doors in the following areas must be equipped with self-closing devises:

1) Hospital equipment storage room
2) Medical equipment storage room

An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility did not properly maintain enclose stairways used for exits and smoke proof enclosures in accordance with NFPA 101 (2012), Life Safety Code, section 7.1.3.2.1. These deficient findings could an isolated impact on the residents within the facility.

Findings include:

On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation that storage materials had been placed in the emergency exit stairwell in the following areas:

1) Stairwell that leads to Old Nursing Home
2) Stairwell leading from the Exp. Back Stairwell

An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.

Based on observation and staff interview the facility failed to provide the level of lighting as required by the Life Safety Code, (NFPA 101) 2012 edition section 7.8.1.4. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation that the exterior lights outside of the exit discharge from stairwell door 14 and outside back door from retail pharmacy each had only one bulb for illumination. Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area.

An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.

Based on observation the facility failed to maintain emergency lighting system per NFPA 101 (2012 edition), Life Safety Code sections 19.2.9.1 and 7.9.1.3. This deficient practice could have a patterned impact on the residents within the facility.

Findings include:

On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation that the facility failed to conduct the annual 90 minute required Emergency Lighting test.

An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.

Based on documentation review and staff interview, the facility failed to test and inspect the kitchen hood ventilation and fire suppression system per NFPA 101 (2012 edition), Life Safety Code, section 9.2.3 and NFPA 96 (2011 edition), Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, section 11.2.1. This deficient finding could have an isolated impact on the residents within the facility.

Findings Include:

On 04/30/2024, between 7:30am and 12:30pm, it was revealed by a review of available documentation that inspection documentation for the kitchen hood ventilation and fire suppression system was not available. The facility could not provide completed test/inspection documentation for both of the semi-annual kitchen hood suppression system inspections for the last 12 months.

An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to maintain spacing between storage and the sprinkler system per NFPA 101 (2012 edition), Life Safety Code, Section 9.7.5, NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 5.2.1.2, and NFPA 13 (2010 edition), Standard for the Installation of Sprinkler Systems, Sections 8.6.5.3.2 and 8.15.9. These deficient findings could a patterned impact on the residents within the facility.

Findings include:

On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation that storage materials had been placed on a storage rack, bringing the storage materials within the required 18 inch clearance area under the sprinkler heads. These obstructions were found in:

1) Clinic Storeroom
2) RQI Room
3) OR Supply Room
4) Disaster / Emergency Management Room
5) Material Storage Room

An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding 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 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation that the following fire doors and/or fire door frames were missing door rating tags.

1) Fire doors leading ER Trauma - Painted tags on door frame
2) Fire doors leading to Out-Patient area - Painted tags on door frame
3) Fire doors leading to In-Patient area - Painted tags on door frame

An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to maintain their smoke barrier per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.1, 19.3.7.3, 8.5.2.2, and 8.5.6.5. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation that there was a penetration running from one smoke compartment to another in the following locations:

1) HDC Area at entrance to Doctor On-Call area
2) Out Patient Exam Doors
3) Double door leading to In-Patient Care Doors
4) Hole in fire barrier wall in the Medical Storage Room

An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to conduct fire drills under varied times and conditions per NFPA 101 (2012 edition), Life Safety Code, sections 19.7.1.6, 4.7.4, and 4.6.1.1. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 04/30/2024, between 7:30am and 12:30pm, it was revealed by a review of available documentation that fire drills did not meet the varying time requirement: second shift 03/28/24 @ 1601, 06/29/23 @ 1603, 09/19/23 @ 1605 and 12/28/23 @ 1600.

An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to implement its portable space heater policy per NFPA 101 (2012 edition), Life Safety Code, section 19.7.8. These deficient findings could have a patterned impact on the residents within the facility.

Findings include:

On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation of portable space heaters in ECO Examination Room.

An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to conduct the electrical testing and maintenance per NFPA 99 Standards for Health Care Facilities 2012 edition, section 6.3.3.2, 6.3.4.1.3, and 6.3.4.2.1.2. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 04/30/2024, between 7:30am and 12:30pm, it was revealed by review of available documentation the acceptable required annual receptacle inspection documentation was not available at the time of the survey.

An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to install and maintain generators per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.3, 6.4.1.1.16.2 and 6.4.1.1.17, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, sections 8.4.9, 8.4.9.1, 8.4.9.2 and 8.4.9.5.1. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 04/30/2024, between 7:30am and 12:30pm, it was revealed by a review of available documentation of the emergency generator maintenance and testing that the facility could not provide documentation that a 36 month four (4) hour load bank test had been performed.

An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices per NFPA 99 (2012 edition), Health Care Facilities Code, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 70, (2011 edition), National Electrical Code, sections 400-8, and UL 1363. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 04/30/2024, between 7:30am and 12:30pm, it was revealed by observation that there were several electrical appliances plugged into a power strip and/or extension cords in the following areas:

1) Doctor-on-call rooms near HDC = multi-plug in all four (4) rooms
2) HDC Conference Room = extension cord
3) HDC Lunchroom = extension cord and power-strip.
4) Nurse Break Room = power-strip
5) Pharmacy Office = Power-strip

An interview with the Director of Radiology, Materials, Maintenance and Housekeeping and Facilities Manager verified this deficient finding at the time of discovery.