HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain doors protecting corridors in one instance on one of four floors.

Findings Include:

1. Observations on March 25, 2015, revealed the following corridor door deficiency:

a) At 10:58 a.m., second floor room door 0206 was being held open with a chair.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the corridor door issue.

Based on observation and interview, it was determined the facility failed to maintain doors protecting corridor openings in one instance on one of four floors.

Findings include:

1. Observation on March 25, 2015, revealed the following:

a) At 1:45 p.m., in the basement, the restroom 0041 the corridor door would not close and latch in its frame.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the vertical penetration issues.

Based on observation and interview it was determined the facility failed to maintain vertical openings in shafts in one instance on 1 of 3 floors.

Findings include:

1. Observation on March 26, 2015, revealed the following shaft penetration deficiency:

a) At 10:35 a.m., the 2nd floor pipe chase, 257, had numerous penetrations around and inside pipes.

Interview with Facility Personnel on March 26, 2015, at 1:20 p.m., confirmed the penetration issue.

Based on observation and interview, it was determined the facility failed to maintain vertical openings in two instances on two of four floors.

Findings include:

1. Observation on March 25, 2015, revealed the following:

a) At 1:10 p.m., in the second floor bathroom 0229, there was a hole in the ceiling.
b) At 1:20 p.m., in the first floor bathroom 0117, there was a hole in the ceiling.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the vertical penetration issues.

Based on observation and interview, it was determined the facility failed to maintain the smoke barrier constructions in six instances on 2 of 4 floors.

Findings Include:

1. Observations on March 25, 2015, revealed the following smoke barrier deficiencies:

a) At 10:21 a.m., the 2nd floor social service office has a penetration inside and around a PVC pipe.
b) At 10:47 a.m., the 2nd floor room 0239 has a penetration around a conduit.
c) At 10:51 a.m., the 2nd floor room 0236 has numerous penetrations around pipes and wires.
d) At 11:19 a.m., the 2nd floor room 227/229 has a penetration around a conduit.
e) At 12:55 p.m., the 3rd floor, above corridor door 0300 has a penetration around a conduit.
f) At 1:21 p.m., the 3rd floor, room 0382 has a penetration around a conduit.

Interview with Facility Personnel on March 24, 2015, at 2:00 p.m., confirmed the smoke wall penetration issues.

Based on observation and interview, it was determined the facility failed to maintain smoke wall doors in one location on 1 of 3 floors.

1. Observations on March 26, 2015, revealed the following smoke wall door deficiency:

a) At 10:39 a.m., the 2nd floor corridor smoke wall door next to room 260 does not close smoke tight due to being recently painted.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the smoke wall door issue.

Based on observation and interview, it was determined the facility failed to maintain smoke wall doors in one location on 1 of 4 floors.

1. Observation on March 25, 2015, revealed the following smoke wall door deficiency:

a) At 10:09 a.m., the corridor smoke wall doors next to the security office, 0103, have a gap greater than 1/8 inch while in the closed position.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the smoke wall door issue.

Based on observation and interview, it was determined the facility failed to maintain exit access in one instances on one of four floors.

Findings include:

1. Observation on March 25, 2015, revealed the following:

a) At 12:30 p.m., in the basement canteen room 034, the panic hardware inside the walk in cooler fails to open the door.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the egress issue.

Based on observation and interview, it was determined the facility failed to maintain battery back-up/task lighting in one location on 1 of 3 floors.

1. Observations on March 25, 2015, revealed the following battery back-up/task lighting deficiency:

a) At 2:15 p.m., the security office control booth battery back-up/task lighting was inoperative.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the battery lighting issue.

Based on observation and interview, it was determined the facility failed to maintain smoke detectors in accordance with regulation throughout the facility.

Findings Include:

1. Observations on March 26, 2015, revealed the following smoke detector deficiency:

a) At 12:50 p.m., the facility lacked documentation identifying that sensitivity testing of the smoke detectors was completed within the previous two years.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the smoke detector issue.

Based on observation and interview, it was determined the facility failed to maintain the supervised automatic sprinkler system in eight instances on three of three floors.

Findings Include:

1. Observations on March 26, 2015, revealed the following sprinkler system deficiency:

a) At 9:07 a.m., in the basement sprinkler room, the gauge mounted on riser panel was dated 2009.
b) At 9:20 a.m., in the basement utility room connected to room 0054 there was a sprinkler missing an escutcheon.
c) At 9:25 a.m., in the basement store room 0039 there was storage on shelving that blocks the effective spray pattern of the sprinkler head.
d) At 10:25 a.m., in the first floor South 1 restroom there was a light fixture obstructing a sprinkler from providing full sprinkler coverage.
e) At 10:35 a.m., in the first floor room 127 there was a light fixture obstructing a sprinkler from providing full sprinkler coverage.
f) At 10:37 a.m., in the first floor room 126B there was a light fixture obstructing a sprinkler from providing full sprinkler coverage.
g) At 10:56 a.m., in the first floor North 1 shower and toilet room there was a solid shower curtain prohibiting full sprinkler coverage.
h) At 11:03 a.m., the 2nd floor shower room 236A there was a solid shower curtain prohibiting full sprinkler coverage.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the automatic sprinkler system issues.

Based on observation and interview, it was determined the facility failed to follow smoking regulations and facility policy in one instance throughout the facility.

Findings Include:

1. Observations on March 26, 2015, revealed the following:

a) At 10:30 a.m., outside the main entrance there was an abundance of discarded cigarette butts in the combustible vegetation and ground cover.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the cigarette butts were present.

Based on documentation review and interview, it was determined the facility failed to maintain an adequate policy for exit access throughout the facility.

1. Review of documentation on March 26, 2015, revealed the following exit egress issues:

a) At 12:45 p.m., the snow removal policy for the facility failed to address that all emergency entrances and exits will be kept clear of ice and snow prior to accumulation, a path 4-feet wide to a common way will be maintained throughout the winter event, entrances and exits will be cleared prior to less critical areas and will be maintained 24/7.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the exit egress issues.

28 Pa. Code § 103.4(3). FUNCTIONS

The governing body, with technical assistance and advice from the hospital staff, shall do the following: (3) Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.

35 P.S. § 448.808. Issuance of license.

(a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;

Based on observation and interview, the facility failed to have state approved plans on site during construction in one area on one of three floors.

Findings include:

1. Observation on March 26, 2015, revealed the following construction issue:

a) At 10:47 a.m., the 2nd floor room 250 was under construction and there were no state approved plans on site.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency diesel generator that provides emergency power for the entire facility.

Findings Include:

Review of documentation on March 26, 2015, revealed the following generator deficiencies:

a) At 12:30 p.m., there was no documentation reflecting that weekly diesel generator inspections were conducted for the past 12 months.
b) At 12:35 p.m., there was no documentation reflecting that the diesel generator was run monthly UNDER LOAD for 30 minutes for the past 12 months.
c) At 12:40 p.m., there was no documentation reflecting that a load bank inspection was conducted on the diesel generator during the past 12 months

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the generator issues.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency diesel generator that provides emergency power for the entire facility.

Findings Include:

Review of documentation on March 26, 2015, revealed the following generator deficiencies:

a) At 12:30 p.m., there was no documentation reflecting that weekly diesel generator inspections were conducted for the past 12 months.
b) At 12:35 p.m., there was no documentation reflecting that the diesel generator was run monthly UNDER LOAD for 30 minutes for the past 12 months.
c) At 12:40 p.m., there was no documentation reflecting that a load bank inspection was conducted on the diesel generator during the past 12 months
.
Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the generator issues.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency propane generator that provides emergency power for the entire facility.

Findings Include:

Review of documentation on March 26, 2015, revealed the following generator deficiencies:

a) At 12:30 p.m., there was no documentation reflecting that weekly propane generator inspections were conducted for the past 12 months.

b) At 12:35 p.m., there was no documentation reflecting that the propane generator was run monthly UNDER LOAD for 30 minutes for the past 12 months.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the generator issues.


32031

Based on observation and interview, it was determined the facility failed to maintain battery operated emergency lighting at one of one generator set locations.

Findings Include:

1. Observations on March 26, 2015, revealed the following battery operated emergency lighting deficiency:

a) At 1:00 p.m., the facility lacked documentation identifying monthly thirty second and annual ninety minute testing of the battery operated emergency lighting at the generator set location was being completed.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the battery operated emergency lighting issue.

Based on observation and interview, it was determined the facility failed to maintain the facility's propane generator and battery operated emergency lighting at one of one generator set locations.

Findings Include:

1. Observations on March 26, 2015, revealed the following generator and battery operated emergency lighting deficiencies:

a) At 12:30 p.m., there was no documentation reflecting that weekly propane generator inspections were conducted for the past 12 months.
b) At 12:35 p.m., there was no documentation reflecting that the propane generator was run monthly UNDER LOAD for 30 minutes for the past 12 months.
c) At 1:00 p.m., the facility lacked documentation identifying monthly thirty second and annual ninety minute testing of the battery operated emergency lighting at the generator set location was being completed.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the generator and battery operated emergency lighting issues.

Based on observation and interview, it was determined the facility failed to maintain the propane generator and battery operated emergency lighting at one of one generator set locations.

Findings Include:

1. Observations on March 26, 2015, revealed the following generator and battery operated emergency lighting deficiencies:

a) At 1:00 p.m., the facility lacked documentation identifying monthly thirty second and annual ninety minute testing of the battery operated emergency lighting at the generator set location was being completed.
b) At 12:30 p.m., there was no documentation reflecting that weekly propane generator inspections were conducted for the past 12 months.
c) At 12:35 p.m., there was no documentation reflecting that the propane generator was run monthly UNDER LOAD for 30 minutes for the past 12 months.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the generator and battery operated emergency lighting issue.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring requirements in nine instances on two of four floors.

Findings Include:

1. Observations on March 25, 2015, revealed the following electrical deficiencies:

a) At 9:45 a.m., there was exposed/unterminated electrical wiring and light bulb above the ceiling in 1st floor room 0169.
b) At 9:57 a.m., there was exposed/unterminated electrical wiring above the ceiling in 1st floor corridor near the elevator machine room, 0138.
c) At 10:23 a.m., there was an open 4"x 4" electrical box on the 2nd floor in the social service office, 0245.
d) At 10:50 a.m., there was one broken electrical outlet inside the 2nd floor day ward.
e) At 10:53 a.m., there was exposed/unterminated electrical wiring above the ceiling in the 2nd floor room 0236.
f) At 10:55 a.m., there was no GFCI electrical outlet for the clothes washer in the 2nd floor room 0243 and no indication that the circuit breaker for the washer was GFCI protected.
g) At 11:25 a.m., there was an open 4"x 4" electrical box on the 2nd floor in the pipe chase room, 0290.
h) At 11:30 a.m., there was a broken electrical outlet outside of room 0277 on the 2nd floor.
i) At 12:59 p.m., there was exposed/unterminated electrical wiring above the ceiling in 2nd floor corridor above corridor door 0300.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the electrical wiring issues.

Based on observation and interview it was determined the facility failed to maintain the electrical requirements in three instances on two of four floors.

Findings include:

1. Observation on March 25, 2015, revealed the following:

a) At 1:10 p.m., in the 2nd floor, shower room 0229, there was exposed electrical wiring for light switches hanging out of the junction box.
b) At 1:50 p.m., in the basement switchgear room 0031, there was unterminated electrical wiring below the rectifier.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the electrical wiring issues.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring requirements in two instances on one of three floors.

Findings Include:

1. Observations on March 26, 2015, revealed the following sprinkler system deficiency:

a) At 9:45 a.m., in the basement room 0009, there was a damaged electrical outlet.
b) At 10:28 a.m., in the basement restroom located within the gym room 0029, there was a heater connected by temporary wiring to a light switch junction box in the adjoining room.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the electrical wiring issues.

Based on observation and interview it was determined the facility failed to maintain the electrical requirements in three instances on two of four floors.

Findings include:

1. Observation on March 25, 2015, revealed the following:

a) At 12:40 p.m., in the basement switchgear room 0028, there was unterminated electrical wiring below the rectifier.
b) At 12:50 p.m., on the first floor, in the kitchen, there was a broken electrical outlet across from the sink.
c) At 12:55 p.m., on the first floor, in the optometrist office, there was an extension cord in use.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the electrical wiring issues.

Based on observation and interview, it was determined the facility failed to maintain the electrical requirements in four instances on one of three floors.

Findings include:

1. Observation on March 25, 2015, revealed the following:

a) At 9:45 a.m., in the basement in room 0030 there was exposed unterminated wiring near the window.
b) At 9:50 a.m., in the basement in room 0008 there was exposed wiring above the compressor.
c) At 10:00 a.m., in the basement in room 0025A there were two (2) uncovered electrical junction boxes.
d) At 10:05 a.m., in the basement in the pharmacy, room 0019 there was an uncovered electrical junction box, below the fire alarm panel.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the electrical wiring issues.

Based on observation and interview, it was determined the facility failed to maintain alcohol based hand rub requirements in one instance on one of four floors.

Findings Include:

1. Observations on March 25, 2015, revealed the following alcohol based hand rub deficiency:

a) At 10:53 a.m., in second floor room 0217 there was an alcohol based hand rub installed over top of an electrical outlet.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the alcohol based hand rub issue.

Based on observation and interview, it was determined the facility failed to maintain doors protecting corridors in one instance on one of four floors.

Findings Include:

1. Observations on March 25, 2015, revealed the following corridor door deficiency:

a) At 10:58 a.m., second floor room door 0206 was being held open with a chair.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the corridor door issue.

Based on observation and interview, it was determined the facility failed to maintain doors protecting corridor openings in one instance on one of four floors.

Findings include:

1. Observation on March 25, 2015, revealed the following:

a) At 1:45 p.m., in the basement, the restroom 0041 the corridor door would not close and latch in its frame.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the vertical penetration issues.

Based on observation and interview it was determined the facility failed to maintain vertical openings in shafts in one instance on 1 of 3 floors.

Findings include:

1. Observation on March 26, 2015, revealed the following shaft penetration deficiency:

a) At 10:35 a.m., the 2nd floor pipe chase, 257, had numerous penetrations around and inside pipes.

Interview with Facility Personnel on March 26, 2015, at 1:20 p.m., confirmed the penetration issue.

Based on observation and interview, it was determined the facility failed to maintain vertical openings in two instances on two of four floors.

Findings include:

1. Observation on March 25, 2015, revealed the following:

a) At 1:10 p.m., in the second floor bathroom 0229, there was a hole in the ceiling.
b) At 1:20 p.m., in the first floor bathroom 0117, there was a hole in the ceiling.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the vertical penetration issues.

Based on observation and interview, it was determined the facility failed to maintain the smoke barrier constructions in six instances on 2 of 4 floors.

Findings Include:

1. Observations on March 25, 2015, revealed the following smoke barrier deficiencies:

a) At 10:21 a.m., the 2nd floor social service office has a penetration inside and around a PVC pipe.
b) At 10:47 a.m., the 2nd floor room 0239 has a penetration around a conduit.
c) At 10:51 a.m., the 2nd floor room 0236 has numerous penetrations around pipes and wires.
d) At 11:19 a.m., the 2nd floor room 227/229 has a penetration around a conduit.
e) At 12:55 p.m., the 3rd floor, above corridor door 0300 has a penetration around a conduit.
f) At 1:21 p.m., the 3rd floor, room 0382 has a penetration around a conduit.

Interview with Facility Personnel on March 24, 2015, at 2:00 p.m., confirmed the smoke wall penetration issues.

Based on observation and interview, it was determined the facility failed to maintain smoke wall doors in one location on 1 of 3 floors.

1. Observations on March 26, 2015, revealed the following smoke wall door deficiency:

a) At 10:39 a.m., the 2nd floor corridor smoke wall door next to room 260 does not close smoke tight due to being recently painted.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the smoke wall door issue.

Based on observation and interview, it was determined the facility failed to maintain smoke wall doors in one location on 1 of 4 floors.

1. Observation on March 25, 2015, revealed the following smoke wall door deficiency:

a) At 10:09 a.m., the corridor smoke wall doors next to the security office, 0103, have a gap greater than 1/8 inch while in the closed position.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the smoke wall door issue.

Based on observation and interview, it was determined the facility failed to maintain exit access in one instances on one of four floors.

Findings include:

1. Observation on March 25, 2015, revealed the following:

a) At 12:30 p.m., in the basement canteen room 034, the panic hardware inside the walk in cooler fails to open the door.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the egress issue.

Based on observation and interview, it was determined the facility failed to maintain battery back-up/task lighting in one location on 1 of 3 floors.

1. Observations on March 25, 2015, revealed the following battery back-up/task lighting deficiency:

a) At 2:15 p.m., the security office control booth battery back-up/task lighting was inoperative.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the battery lighting issue.

Based on observation and interview, it was determined the facility failed to maintain smoke detectors in accordance with regulation throughout the facility.

Findings Include:

1. Observations on March 26, 2015, revealed the following smoke detector deficiency:

a) At 12:50 p.m., the facility lacked documentation identifying that sensitivity testing of the smoke detectors was completed within the previous two years.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the smoke detector issue.

Based on observation and interview, it was determined the facility failed to maintain the supervised automatic sprinkler system in eight instances on three of three floors.

Findings Include:

1. Observations on March 26, 2015, revealed the following sprinkler system deficiency:

a) At 9:07 a.m., in the basement sprinkler room, the gauge mounted on riser panel was dated 2009.
b) At 9:20 a.m., in the basement utility room connected to room 0054 there was a sprinkler missing an escutcheon.
c) At 9:25 a.m., in the basement store room 0039 there was storage on shelving that blocks the effective spray pattern of the sprinkler head.
d) At 10:25 a.m., in the first floor South 1 restroom there was a light fixture obstructing a sprinkler from providing full sprinkler coverage.
e) At 10:35 a.m., in the first floor room 127 there was a light fixture obstructing a sprinkler from providing full sprinkler coverage.
f) At 10:37 a.m., in the first floor room 126B there was a light fixture obstructing a sprinkler from providing full sprinkler coverage.
g) At 10:56 a.m., in the first floor North 1 shower and toilet room there was a solid shower curtain prohibiting full sprinkler coverage.
h) At 11:03 a.m., the 2nd floor shower room 236A there was a solid shower curtain prohibiting full sprinkler coverage.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the automatic sprinkler system issues.

Based on observation and interview, it was determined the facility failed to follow smoking regulations and facility policy in one instance throughout the facility.

Findings Include:

1. Observations on March 26, 2015, revealed the following:

a) At 10:30 a.m., outside the main entrance there was an abundance of discarded cigarette butts in the combustible vegetation and ground cover.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the cigarette butts were present.

Based on observation and interview, it was determined the facility failed to maintain fire, ceiling, and smoke damper inspection requirements throughout the facility

Findings Include:

1. Observations on March 26, 2015, revealed the following fire, ceiling, smoke damper deficiency:

a) At 12:40 p.m., facility documentation indicated that the last fire, ceiling, and smoke damper inspection was completed in January 2009. Fire, ceiling, and smoke dampers are to be inspected/exercised every four years.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the fire, ceiling, and smoke damper issue.

Based on documentation review and interview, it was determined the facility failed to maintain an adequate policy for exit access throughout the facility.

1. Review of documentation on March 26, 2015, revealed the following exit egress issues:

a) At 12:45 p.m., the snow removal policy for the facility failed to address that all emergency entrances and exits will be kept clear of ice and snow prior to accumulation, a path 4-feet wide to a common way will be maintained throughout the winter event, entrances and exits will be cleared prior to less critical areas and will be maintained 24/7.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the exit egress issues.

28 Pa. Code § 103.4(3). FUNCTIONS

The governing body, with technical assistance and advice from the hospital staff, shall do the following: (3) Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.

35 P.S. § 448.808. Issuance of license.

(a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;

Based on observation and interview, the facility failed to have state approved plans on site during construction in one area on one of three floors.

Findings include:

1. Observation on March 26, 2015, revealed the following construction issue:

a) At 10:47 a.m., the 2nd floor room 250 was under construction and there were no state approved plans on site.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency diesel generator that provides emergency power for the entire facility.

Findings Include:

Review of documentation on March 26, 2015, revealed the following generator deficiencies:

a) At 12:30 p.m., there was no documentation reflecting that weekly diesel generator inspections were conducted for the past 12 months.
b) At 12:35 p.m., there was no documentation reflecting that the diesel generator was run monthly UNDER LOAD for 30 minutes for the past 12 months.
c) At 12:40 p.m., there was no documentation reflecting that a load bank inspection was conducted on the diesel generator during the past 12 months

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the generator issues.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency diesel generator that provides emergency power for the entire facility.

Findings Include:

Review of documentation on March 26, 2015, revealed the following generator deficiencies:

a) At 12:30 p.m., there was no documentation reflecting that weekly diesel generator inspections were conducted for the past 12 months.
b) At 12:35 p.m., there was no documentation reflecting that the diesel generator was run monthly UNDER LOAD for 30 minutes for the past 12 months.
c) At 12:40 p.m., there was no documentation reflecting that a load bank inspection was conducted on the diesel generator during the past 12 months
.
Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the generator issues.

Based on documentation review and interview, it was determined the facility failed to maintain the emergency propane generator that provides emergency power for the entire facility.

Findings Include:

Review of documentation on March 26, 2015, revealed the following generator deficiencies:

a) At 12:30 p.m., there was no documentation reflecting that weekly propane generator inspections were conducted for the past 12 months.

b) At 12:35 p.m., there was no documentation reflecting that the propane generator was run monthly UNDER LOAD for 30 minutes for the past 12 months.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the generator issues.


32031

Based on observation and interview, it was determined the facility failed to maintain battery operated emergency lighting at one of one generator set locations.

Findings Include:

1. Observations on March 26, 2015, revealed the following battery operated emergency lighting deficiency:

a) At 1:00 p.m., the facility lacked documentation identifying monthly thirty second and annual ninety minute testing of the battery operated emergency lighting at the generator set location was being completed.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the battery operated emergency lighting issue.

Based on observation and interview, it was determined the facility failed to maintain the facility's propane generator and battery operated emergency lighting at one of one generator set locations.

Findings Include:

1. Observations on March 26, 2015, revealed the following generator and battery operated emergency lighting deficiencies:

a) At 12:30 p.m., there was no documentation reflecting that weekly propane generator inspections were conducted for the past 12 months.
b) At 12:35 p.m., there was no documentation reflecting that the propane generator was run monthly UNDER LOAD for 30 minutes for the past 12 months.
c) At 1:00 p.m., the facility lacked documentation identifying monthly thirty second and annual ninety minute testing of the battery operated emergency lighting at the generator set location was being completed.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the generator and battery operated emergency lighting issues.

Based on observation and interview, it was determined the facility failed to maintain the propane generator and battery operated emergency lighting at one of one generator set locations.

Findings Include:

1. Observations on March 26, 2015, revealed the following generator and battery operated emergency lighting deficiencies:

a) At 1:00 p.m., the facility lacked documentation identifying monthly thirty second and annual ninety minute testing of the battery operated emergency lighting at the generator set location was being completed.
b) At 12:30 p.m., there was no documentation reflecting that weekly propane generator inspections were conducted for the past 12 months.
c) At 12:35 p.m., there was no documentation reflecting that the propane generator was run monthly UNDER LOAD for 30 minutes for the past 12 months.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the generator and battery operated emergency lighting issue.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring requirements in nine instances on two of four floors.

Findings Include:

1. Observations on March 25, 2015, revealed the following electrical deficiencies:

a) At 9:45 a.m., there was exposed/unterminated electrical wiring and light bulb above the ceiling in 1st floor room 0169.
b) At 9:57 a.m., there was exposed/unterminated electrical wiring above the ceiling in 1st floor corridor near the elevator machine room, 0138.
c) At 10:23 a.m., there was an open 4"x 4" electrical box on the 2nd floor in the social service office, 0245.
d) At 10:50 a.m., there was one broken electrical outlet inside the 2nd floor day ward.
e) At 10:53 a.m., there was exposed/unterminated electrical wiring above the ceiling in the 2nd floor room 0236.
f) At 10:55 a.m., there was no GFCI electrical outlet for the clothes washer in the 2nd floor room 0243 and no indication that the circuit breaker for the washer was GFCI protected.
g) At 11:25 a.m., there was an open 4"x 4" electrical box on the 2nd floor in the pipe chase room, 0290.
h) At 11:30 a.m., there was a broken electrical outlet outside of room 0277 on the 2nd floor.
i) At 12:59 p.m., there was exposed/unterminated electrical wiring above the ceiling in 2nd floor corridor above corridor door 0300.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the electrical wiring issues.

Based on observation and interview it was determined the facility failed to maintain the electrical requirements in three instances on two of four floors.

Findings include:

1. Observation on March 25, 2015, revealed the following:

a) At 1:10 p.m., in the 2nd floor, shower room 0229, there was exposed electrical wiring for light switches hanging out of the junction box.
b) At 1:50 p.m., in the basement switchgear room 0031, there was unterminated electrical wiring below the rectifier.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the electrical wiring issues.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring requirements in two instances on one of three floors.

Findings Include:

1. Observations on March 26, 2015, revealed the following sprinkler system deficiency:

a) At 9:45 a.m., in the basement room 0009, there was a damaged electrical outlet.
b) At 10:28 a.m., in the basement restroom located within the gym room 0029, there was a heater connected by temporary wiring to a light switch junction box in the adjoining room.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the electrical wiring issues.

Based on observation and interview it was determined the facility failed to maintain the electrical requirements in three instances on two of four floors.

Findings include:

1. Observation on March 25, 2015, revealed the following:

a) At 12:40 p.m., in the basement switchgear room 0028, there was unterminated electrical wiring below the rectifier.
b) At 12:50 p.m., on the first floor, in the kitchen, there was a broken electrical outlet across from the sink.
c) At 12:55 p.m., on the first floor, in the optometrist office, there was an extension cord in use.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the electrical wiring issues.

Based on observation and interview, it was determined the facility failed to maintain the electrical requirements in four instances on one of three floors.

Findings include:

1. Observation on March 25, 2015, revealed the following:

a) At 9:45 a.m., in the basement in room 0030 there was exposed unterminated wiring near the window.
b) At 9:50 a.m., in the basement in room 0008 there was exposed wiring above the compressor.
c) At 10:00 a.m., in the basement in room 0025A there were two (2) uncovered electrical junction boxes.
d) At 10:05 a.m., in the basement in the pharmacy, room 0019 there was an uncovered electrical junction box, below the fire alarm panel.

Interview with Facility Personnel on March 26, 2015, at 1:30 p.m., confirmed the electrical wiring issues.