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Based on record review the facility failed to plan and implement a provision of subsistence needs for the staff and the residents. This affects all occupants in the facility.

Findings include:

1. Review of the EP plan, policies, and procedures on 4/15/24, reflected the facility's emergency plan lacked policies and procedures for subsistence needs for staff and residents, particularly specific policies describing alternate sources of energy to maintain proper temperatures, emergency lighting, and for the life safety systems such as sprinkler, fire alarm, and smoke detection.

Based on record review, the facility failed to develop policies and procedures related to the emergency and standby power systems for the EP plan. The record review showed insufficient information about the role of the emergency generator meeting care needs of the patients, the other occupants, as well as the building's needs based on the facility's safety and hazard vulnerability assessment.

This deficiency affects all of the occupants in the facility.

Findings Include:

1. Review of the EP plan on 4/15/24 reflected a lack of specific details about the emergency generator and what kind of services could be supported by the onsite emergency generator, i.e., the building temperatures, daily kitchen functions, safe food storage, illumination of the exit halls and exit signs, and the fire alarm, extinguishing and detection systems in the building.

Based on observation, the facility failed to maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Sections 7.2.1.5.10.2.

Findings include:

1. During an observation on 4/15/24 at 3:15 p.m., the basement storage room was inspected. The corridor door was found to have a two-step locking mechanism installed, meaning, it was fitted with a lock which required more than one motion to open the doors. The room had the capacity to hold three or more people.

2. During an observation on 4/15/24 at 3:17 p.m., the central supply room in the basement was inspected. The corridor door was found to have a two-step locking mechanism installed, meaning, it was fitted with a lock which required more than one motion to open the doors. The room had the capacity to hold three or more people.

3. During an observation on 4/15/24 at 3:20 p.m., the laundry room was inspected. The corridor door was found to have a two-step locking mechanism installed, meaning, it was fitted with a lock which required more than one motion to open the doors. The room had the capacity to hold three or more people.

Based on observation, the facility failed to ensure hazardous rooms/areas had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 4/15/24 at 2:40 p.m., the soiled utility room on the LTC side was inspected. It is considered a hazardous area. The corridor door to the room failed to close and latch under the power of the self-closer.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).

Findings include:

1. During an observation on 4/15/24 at 2:23 p.m., the south hall corridor was inspected. There was an ABHR station mounted over an outlet in the hall, just outside the supply room.

Based on observations, the facility did not have fire suppression sprinklers under the basement crawl area per NFPA 101, 2012 Edition, Section 19.1.6.1 and Table 19.1.6.1.

Findings include:

1. After review of previous survey reports and a discussion with the maintenance supervisor on 4/15/24, the crawl space under the South Wing of the original hospital building was observed on 4/15/24 and it is not sprinklered as required by NFPA 101 for Type V (111) construction. This crawl space is viewed as a concealed combustible space since the wood floor joists and wood deck are exposed. Although sprinkler mains run through this crawl space, sprinkler heads were not installed.

Based on observation, interview, and record review the facility failed to:

a) complete a 5-year internal inspection of the sprinkler piping in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 14.2.1.,

b) ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.

Findings include:

1. A review of facility records was unable to determine when or if the 5-year internal inspection of the sprinkler system had been completed in the last five years. There was nothing noted on the sprinkler reports nor was there any information of such on the standpipe.

In an interview on 4/23/24 at 10:50 a.m., staff member A stated the vendor was looking for it and had not located the information as of that time.

2. During an observation on 4/15/24 at 3:30 p.m., the boiler room was inspected. There was a large vent pipe for the gas-fired water heater which was found to be supported off the over-head sprinkler pipes. There was also copper piping for the water heater found to be supported from the over-head sprinkler pipes.

3. During an observation on 4/15/24 at 3:35 p.m., the maintenance office was inspected. There was an electrical conduit going to a ceiling mounted light in the room which was taped to a sprinkler pipe in the room.

Based on observation, the facility failed to ensure doors were resistant to the passage of smoke in accordance with NFPA 101, 2012 Edition, Sections 19.3.6.3.1.

Findings include:

1. During an observation on 4/15/24 at 3:20 p.m., the basement laundry door was inspected. The door was found to have a large gap on the lower half of the door on the latch side of the door. It was too large to be resistant to the passage of smoke.

Based on observation, the facility failed to maintain corridor doors without openings or transfer grilles in accordance with NFPA 101, 2012 Edition, Section 19.3.6.4.1.

Findings include:

1. During an observation on 4/15/24 at 2:47 p.m., the acute side corridor was inspected. There were transfer grilles in corridor doors in the IT room, the biohazard room, and the "empty" oxygen storage room. Only bathrooms and janitors closets may have transfer grilles in corridor doors.

Based on observation, the facility failed to ensure the resident smoking area was confined to a safe area, in accordance with NFPA 101, 2012 Edition, Section 19.7.4.(5).

Findings include:

1. During an observation on 4/15/24 at 2:11 p.m., the smoking courtyard was inspected. Along the side of the building away from the courtyard, there was an area which staff used to smoke. There was no metal can with a self-closing lid. There was however, two other large garbage cans with regular trash inside, one of which had cigarette butts thrown in. In the courtyard was another garbage can which was not self-closing, in which more cigarette butts were thrown in. There was a smoking resident being supervised in another part of the courtyard in an area which lacked any portable extinguisher, and a metal can with a self-closing lid, along with another plastic garbage can with trash and more cigarette butts discarded inside.

The facility failed to provide any facility-wide smoking policy which was requested upon exit.

Based on observation, the facility failed to ensure the resident smoking area was confined to a safe area, in accordance with NFPA 101, 2012 Edition, Section 19.7.4.(5).

This deficiency affects all independent smokers.

Findings include:

1. During an observation on 4/15/24 at 2:11 p.m., the smoking courtyard was inspected. Along the side of the building away from the courtyard, there was an area which staff used to smoke. There was no metal can with a self-closing lid. There was however, two other large garbage cans with regular trash inside, one of which had cigarette butts thrown in. In the courtyard was another garbage can which was not self-closing, in which more cigarette butts were thrown in. There was a smoking resident being supervised in another part of the courtyard in an area which lacked any portable extinguisher, and a metal can with a self-closing lid, along with another plastic garbage can with trash and more cigarette butts discarded inside.

The facility failed to provide any facility-wide smoking policy which was requested upon exit.

Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report).

Findings include:

1. Review of the fire safety maintenance records on 4/15/24., reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangement in the building and show inspections of all components of the doors in those barriers.

Based on observation and interview, the facility failed to utilize portable space heaters in a health care occupancy in accordance with NFPA 101, 2012 Edition, Section 19.7.8.

Findings Include:

1. During an observation on 4/15/24 at 2:35 p.m., resident room 11 was inspected. There was a portable space heater in use in the room. Portable space heaters are not allowed in resident rooms.

Based on interview and record review, the facility failed to complete annual receptacle testing of non-hospital grade receptacles in patient care areas.

Findings include:

During an interview on 4/15/24 at 12:30 p.m., staff member A stated he had not completed the receptacle retention testing. He had the tool for it, but it was not done.

Record review on 4/15/24 revealed non-hospital grade receptacles located in patient care rooms in the facility did not have annual retention testing as required by sections 6.3.4.1.2 and 6.3.4.1.3 in NFPA 99, Health Care Facilities Code, 2012 Edition.

Actual NFPA Standard: NFPA 99 (2012), 6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on interview and record review, the facility failed to complete annual receptacle testing of non-hospital grade receptacles in patient care areas. This deficiency affects all staff and residents in the facility.

Findings include:

During an interview on 4/15/24 at 12:15 p.m., staff member A stated he had not completed the receptacle retention testing. He had the tool for it, but it was not done.

Record review on 4/15/24 revealed non-hospital grade receptacles located in patient care rooms in the facility did not have annual retention testing as required by sections 6.3.4.1.2 and 6.3.4.1.3 in NFPA 99, Health Care Facilities Code, 2012 Edition.

Actual NFPA Standard: NFPA 99 (2012), 6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on observation, the facility failed to ensure that the oxygen storage locations were maintained, and oxygen was stored in accordance with NFPA 99-2012 Edition, Sections 11.3.4.1, 11.3.4.2, 11.3.2.3, and 11.3.3.

Findings include:

1. During an observation on 4/15/24 at 2:20 p.m., the oxygen storage area was observed. The oxygen storage area was located in the south hall supply and equipment room and it lacked a cautionary oxygen sign. The sign must include the following wording as a minimum:

CAUTION:
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

There was also several combustible slings hung above the oxygen rack and were hanging down and resting on top of the oxygen tanks.

2. During an observation on 4/15/24 at 2:25 p.m., while inspecting the patient rooms, it was found the facility was found to be storing large K-sized oxygen tanks in rooms 3, 9 and 10. This is not allowed as only 300 cubic feet of oxygen is allowed to be stored outside the oxygen storage room. Each K tank holds 250 cubic feet of oxygen.