HospitalInspections.org

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*This tag is a rewrite from the last survey.

Based on review of documentation and interview, the facility failed to provide documentation on the automatic sprinkler system quarterly inspections per the requirements of:

2012 NFPA 101, 19.3.5.1
2012 NFPA 101, 9.7.5
2012 NFPA 101, 9.7.7
2012 NFPA 101, 9.7.8
2011 NFPA 25, Table 5.1.1.2

Findings Include:

On 05/02/2017, during the review of documentation from 11:30 am to 12:15 pm, the facility failed to provide documentation for the quarterly sprinkler inspections. The last documentation of a sprinkler inspection provided was an annual inspection conducted on 01/20/2016.

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 install the portable fire extinguishers per the requirements of:

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

Findings include:

On 05/02/2017, during a tour of the facility from 07:45 am to 12:30 pm, portable fire extinguishers were observed installed more than 5 ft. from the floor to the top of the fire extinguishers (approximately 65") in the following locations:

1. The Front Lobby
2. The Business Office
3. The Laboratory 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 portable fire extinguishers per the requirements of:

2012 NFPA 101, 19.3.5.12
2012 NFPA 101, 9.7.4.1
2010 NFPA 10, 7.2.1.2*

Findings include:

On 05/02/2017, during a tour of the facility from 07:45 am to 12:30 pm, the portable fire extinguishers were observed without documentation of being inspected for the month of April in the following locations:

1. The Outside Mechanical Room
2. The Oxygen Storage Area
3. The Cat Scan Trailer

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 corridor doors per the requirements of:

2012 NFPA 101, 19.3.6.3.5*

This deficiency could affect 5 residents.

Findings include:

On 05/02/2017, during a tour of the facility from 7:45 am to 12:30 pm, the Lab corridor door did not positive latch when testing of the corridor doors.

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

Based on observation and interview, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and resist the passage of smoke per the requirements of:

Review of 2012 NFPA 101, 19.3.7.3
Review of 2012 NFPA 101, 8.5.1
Review of 2012 NFPA 101, 8.5.6.2

This deficiency could affect 10 residents.

Findings include:

On 05/02/2017, during a tour of the facility from 07:45 am to 12:30 pm, the smoke barriers were observed with unsealed 3" conduit pipe with copper tubing and electrical wire, that penetrated the smoke barriers above the ceiling in the following locations:

1. At room 201
2. At room 208

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 designated smoking area per the requirements of:

2012 NFPA 101, 19.7.4* (5),(6)

Findings include:

On 05/02/2017, during a tour of the facility from 07:45 am to 12:30 pm, the designated smoking area was observed without the following items:

1. Ashtray of noncombustible material
2. Metal container with self-closing cover device

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 documentation of testing the diesel generator 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, 8.3.2.1, 8.4.1, 8.4.2, and 8.4.2.3

This could affect 10 patients.

Findings include:

On 05/02/2017, during a tour of the facility from 07:45 am to 12:30 pm, based on review of documentation and interview the facility failed to test the 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.

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 oxygen storage area per the requirements of:

2012 NFPA 99, 11.6.5.3

Findings include:

On 05/02/2017, during a tour of the facility from 07:45 am to 12:30 pm, the empty oxygen cylinders were observed not marked to avoid confusion and delay.

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 ensure the continuous training of personnel on the handling and risk of medical gases and cylinders per the requirements of:

2012 NFPA 99, 11.5.2.1

This deficiency could affect 10 patients.

Findings include:

On 05/02/2017, during the review of documentation from 07:45 am to 12:30 pm, the facility failed to provide documentation on the continuous training of personnel on the handling and risk of medical gases and cylinders.

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