HospitalInspections.org

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Based on observations during the tour of the facility on 12/11/18, the facility failed to provide documentation that all doucumented deficiency assessment items listed in a 10/11/18 report have been corrected.

The Plant Maintenance Director provided a list 61 items that included fire sprinkler, door hardware, exhaust fans, toilet accessories, electrical, unsealed penetrations at rated walls, signage, and fire extinguishers minor deficiencies.

The Plant Maintenance Director stated that documentation indicating corrections of each item will be provided.
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Based on review of records during the survey of facility on 12/11/18, the facility failed to provide documentation of the Fire Marshal Annual Report was conducted as required.

The provided information observed indicated the last Fire Marshal Inspection Report was performed on 03/21/16.

The Plant Maintenance Director stated that the Fire Marshal will be scheduled to perform an annual inspection as soon as possible and the report with documentation will be provided.
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Based on review of records during the survey of facility on 12/11/18, the facility failed to provide documentation of Fire Drills at 15 of 26 buildings were conducted as required.

The provided information observed indicated the last fire drill performed at Ferguson was on 05/03/18, Goldsmith was on 01/12/18, Logan was on 04/30/18, Main was on 04/30/18, Motor was on 09/26/17, Property was on 11/18/16, Seidel was on 01/12/18, Bowie was on 01/12/18, Community was on 09/26/17, Central Kitchen was on 04/30/18, Canteen was on 03/28/17, Chapel was on 09/26/17, Cottages was on 08/31/18, Environmental was on 11/21/17, and Crockett was on 08/17/18.

The Plant Maintenance Director stated that all required fire drills will be performed and all documentation will be provided.
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