HospitalInspections.org

Based on document review and staff interview it was revealed the facility failed to provide emergency lighting in accordance with National Fire Protection Association (NFPA) 101. The facility's census was two (2).

Findings include:

1. Document review on 08/23/21 between the hours of 11:30 a.m. and 4:30 p.m. revealed the facility failed to conduct annual tests of the emergency lighting in accordance with NFPA 101.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/24/21 at approximately 4:00 p.m. at the time of exit and they agreed this deficiency needed corrected.

Based on observation and staff interview it was revealed the facility failed to ensure the facility was protected throughout by an approved automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13. This deficient practice could affect all residents, staff and visitors in the areas referenced. The facility's census was two (2).

Findings include:

1. Observation during the facility inspection tour on 08/24/21 between the hours of 8:30 a.m. and 3:30 p.m. revealed a sprinkler head in emergency room (ER) three (3) closet. A light fixture is located less than twelve (12) inches away from a sprinkler head and exceeded the maximum allowable distance of the sprinkler deflector above the bottom of the light fixture.

2. Observation during the facility inspection tour on 08/24/21 between the hours of 8:30 a.m. and 3:30 p.m. revealed a sprinkler head in the medical records room two (2) closet. A light fixture is located less than twelve (12) inches away from a sprinkler head and exceeded the maximum allowable distance of the sprinkler deflector above the bottom of the light fixture.

3. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/24/21 at approximately 4:00 p.m. at the time of exit and they agreed this deficiency needed corrected.

Based on document review and staff interview it was determined the facility failed to conduct fire drills at unexpected times under varying conditions in accordance with National Fire Protection Association (NFPA). This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census was two (2).

Findings include:

1. Facility document review conducted on 08/23/21 between the hours of 11:30 a.m. and 4:30 p.m. revealed a first quarter, midnight shift fire drill conducted on 03/10/21 at 6:30 a.m. and the second quarter, midnight shift fire drill conducted on 06/17/21 at 6:00 a.m. The fire drills are held within one (1) hour of each other and considered patterned and not at unexpected times under varying conditions.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/24/21 at approximately 4:00 p.m. at the time of exit and they agreed this deficiency needed corrected.

Based on facility document review and staff interview it was revealed the facility failed to maintain the electrical system maintenance and testing requirements in accordance with NFPA 99. The facility's census was two (2).

Findings include:

1. Facility document review conducted on 08/23/21 between the hours of 11:30 a.m. and 4:30 p.m. revealed the facility failed to test receptacles located at patient bed locations in accordance with NFPA 99.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/24/21 at approximately 4:00 p.m. at the time of exit and they agreed this deficiency needed corrected.