HospitalInspections.org

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This tag is a rewrite from the last survey.

Based on observation and interview, the facility failed to maintain a corridor means of egress per the requirements of:

2012 NFPA 101, 19.2.3.4 (5) (a)

Findings include:

On 10/10/2018, during a tour of the facility from 9:00 am to 2:30 pm, the surveyor observed three unsecured chairs in the corridor means of egress at the Nurses' Station at the Radiology Department.

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation and interview, the facility failed to maintain the smoke detectors per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, 14.4.5.3.2

This deficiency could affect all residents.

Findings include:

On 10/10/2018, during a tour of the facility from 9:00 am to 2:30 pm, the facility failed to provide documentation that a smoke detector sensitivity test had been conducted within the past two years.

A member of the maintenance staff was present when this deficiency was identified.
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This tag is a rewrite from the last survey.

Based on review of documentation, observation and interview, the facility failed to maintain the automatic sprinkler system per requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.5
2011 NFPA 25, 5.2.1.1.2 (6), 14.2.1, 5.3.2.1, 5.2.4.1, and 5.2.4.2

1. On 10/10/2018, during a tour of the facility from 9:00 am to 2:30 pm, the surveyor observed the outside sprinkler on the wall at the Ped's Hall exit was painted (not by the manufacturer).
2. On 10/10/2018, during a tour of the facility from 9:00 am to 2:30 pm, the facility failed to provide documentation of the following:
a. The 5 year internal inspection of piping of the automatic sprinkler systems
b. The automatic sprinkler systems riser gauges have been replaced or calibrated within the past 5 years
c. The monthly inspections of the gauges on the wet pipe sprinkler systems
d. The weekly inspections of the gauges on the dry pipe sprinkler systems

A member of the maintenance staff was present when the deficiency was found.
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39327

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Based on observation and interview, the facility failed to install the portable fire extinguishers per the requirements of:

2012 NFPA 101, 19.3.5.12, and 9.7.4.1
2010 NFPA 10, 6.1.3.8.1

Findings include:

On 10/10/2018, during a tour of the facility from 9:00 am to 2:30 pm, the surveyor observed portable fire extinguishers installed more than 5 ft. from the floor to the top of the fire extinguishers (approximately 68") throughout the entire facility.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain the electrical wiring and equipment per the requirements of:

2012 NFPA 101, 19.5.1.1, and 9.1.2
2011 NFPA 70, 314.28(c), and 408.7

Findings include:

On 10/10/2018, during a tour of the facility from 9:00 am to 2:30 pm, the following was observed:
1. The following electrical junction boxes (4" x 4") were observed missing their cover plates:
a. At the Time Clock area
b. In the Autoclave Room
2. The Electrical Panel near Room 125 was observed with an open space

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation and interview, the facility failed to provide a fire safety plan containing all nine items per the requirements of:

2012 NFPA 101, 19.7.2.2 (3)

Findings include:

On 10/10/2018, during a tour of the facility from 9:00 am to 2:30 pm, the facility failed to provide a complete fire safety plan that included an "emergency phone call to the fire department".

A member of the maintenance staff was present when this deficiency was identified.

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This tag is a rewrite from the last survey.

Based on observation and interview, the facility failed to maintain the designated smoking area per the requirements of:

2012 NFPA 101, 19.7.4 (1), (5)

Findings include:

On 10/10/2018, during a tour of the facility from 9:00 am to 2:30 pm, the surveyor observed the following:
1. The grounds near and at the Oxygen Storage was being used as a smoking area. Cigarette butts were observed in front of the Oxygen Storage and directly behind the combustible wooden fence that is less than one foot from the oxygen cylinders.
2. The metal container with a self-closing cover device for ashtrays to be emptied into, was being used as a garbage can (cigarette packs and can items were observed) in the designated smoking area at the rear of the facility.

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation and interview, the facility failed to maintain the fire door assemblies per the requirements of:

2012 NFPA 101, 19.7.6, and 8.3.3.1
2010 NFPA 80, 5.2, and 5.2.3

This deficiency could affect 8 of 16 smoke compartments.

Findings include:

On 10/10/2018, during a tour of the facility from 9:00 am to 2:30 pm, the facility failed to provide documentation of the annual fire door assembly inspection and testing for the past 12 months for the fire door assemblies in the facility.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, review of documentation, and interview, the facility failed to maintain the medical gas master alarm panels per the requirements of:

NFPA 99, 5.1.9.2.4 (7)

Findings include:

On 10/10/2018, during a tour of the facility from 9:00 am to 2:30 pm, the surveyor observed the following:
1. The inspection and preventive maintenance report from LifeGas listed the high/low pressure alarm "not present/not functioning" properly as a deficiency.
2. No documentation was provided to indicate that the repairs were made.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation and interview, the facility failed to maintain the receptacles not listed as hospital-grade and the Line Isolation Monitors (LIM) per the requirements of:

2012 NFPA 99, 6.3.4.1.3, and 6.3.4.1.4

Findings include:

On 10/10/2018, during a tour of the facility from 9:00 am to 2:30 pm, the facility failed to provide the following documentation:
1. The testing of the receptacles not listed as hospital-grade at the residents' bed locations and where deep sedation or general anesthesia is administered within the past 12 months.
2. The monthly testing of the Line Isolation Monitors (LIM) for the past 12 months.

A member of maintenance staff was present when this deficiency was identified.

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Based on review of documentation and interview, the facility failed to maintain the diesel generators per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, 8.4.2, 8.4.2.3, 8.4.9, and 8.3.8

Findings include:

On 10/10/2018, during a tour of the facility from 9:00 am to 2:30 pm, the facility failed to provide the following documentation:
1. Testing of the Kohler 60 kW diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature OR under operating temperature conditions at not less than 30% of the nameplate kW rating OR provide an annual 1.5 hour supplemental load test at not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less 75% of the EPS nameplate kW rating for one continuous hour for a total test duration of not less than 1.5 continuous hours.

2. The following Level 1 EPSS were tested within the past 36 months for 4 continuous hours:
a. Kohler 50 kW Generator
b. Kohler 60 kW Generator

3. The following diesel generators had a fuel quality test performed within the past 12 months using tests approved by ASTM standards:
a. Kohler 200 kW Generator
b. Kohler 60 kW Generator

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to prohibit the use of plug adaptors per the requirements of:

2012 NFPA 99, 10.2.4.2.1
S&C 14-46-LSC

On 10/10/2018, during a tour of the facility from 9:00 am to 2:30 pm, the surveyor observed multi-plug adapters in the following locations:
1. Patient Room 126
2. Patient Room 128

A member of the maintenance staff was present when this deficiency was identified.
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This tag is a rewrite from the last survey.

Based on observation, review of documentation, and interview, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 5.1.3.3.2 (3), 11.3.2.1, and 11.3.2.3

Findings include:

On 10/10/2018, during a tour of the facility from 9:00 am to 2:30 pm, the surveyor observed oxygen cylinders were stored within 20 feet of combustible materials (trash cans and a wooden fence) under the outdoor Oxygen Storage Shed.

A member of the maintenance staff was present when this deficiency was identified.