HospitalInspections.org

Based on observation and staff interview, the facility did not properly separate and protect hazardous areas. 19.3.2.1. This deficient practice could affect all residents within the surgical suite.

Findings include:

On a facility tour between the hours of 1330 and 1530 on January 02, 2018, observation revealed that the operating room cores had rolling trash receptacles in the suite corridors that exceeded 300 gallons in capacity..


This deficient practice was verified by the Director of Plant Operations & Infrastructure at the time of discovery.

Based on observation and staff interview, the facility did not install and maintain cooking equipment in accordance with NFPA 96 and NFPA 101. 19.3.2.5.2, 19.3.2.5.3, 19.3.2.5.4, 19.3.2.5.1, 19.3.2.5.5. This deficient practice could affect all patients within the smoke compartment.

Findings include:

On a facility tour between the hours of 1000 and 1200 on January 03, 2018, observation revealed that the residential cooking oven in Kenny Square Rehab did not have a remote isolation lockout to disconnect power to the oven when not in use.


This deficient practice was verified by the Director of Facilities Management at the time of discovery.

Based on observation and staff interview, the facility did not install and maintain alcohol based hand rub dispensers (ABHR) away from ignition sources and within accordance with NFPA 101 (2012), Life Safety Code. 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485. This deficient practice could effect all patients in the suite.

Findings include:

On a facility tour between the hours of 1330 and 1530 on January 02, 2018, observation revealed that there ABHR dispensers mounted directly above electrical light switches in the sixth floor exam rooms..


This deficient practice was verified by the Maintenance Engineering Manager at the time of discovery.

Based on observation and staff interview, the facility failed to ensure the construction of corridor walls resisted the passage of smoke. 19.3.6.2, 19.3.6.2.7. This deficient practice could effect all patients in the smoke compartment.

Findings include:

On a facility tour between the hours of 1330 and 1530 on January 02, 2018, observation revealed that there were penetrations in the corridor wall, above the ceiling outside of suite 5659.


This deficient practice was verified by the Maintenance Engineering Manager at the time of discovery.

Based on observation and staff interview, that facility did not properly store oxygen cylinders in accordance with NFPA 99. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5. This deficient practice could affect all patients in the smoke compartment.

Findings include:

On a facility tour between the hours of 1330 and 1530 on January 02, 2018, observation revealed that there was oxygen storage in room H7205 without proper signage.


These deficient practices was verified by the Facility Manager at the time of discovery.

Based on observation and staff interview, that facility did not properly store oxygen cylinders in accordance with NFPA 99. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5. This deficient practice could affect all patients in the surgical suite.

Findings include:

On a facility tour between the hours of 1330 and 1530 on January 02, 2018, observation revealed that in room G414, oxygen cylinders were being stored within five feet of combustible storage.


These deficient practices was verified by the Director of Plant Operations & Infrastructure at the time of discovery.