The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

VIOLATION: General Requirements - Other Tag No: K0100
Based on record review, observations and interview with Director of Maintenance (DOM), the facility failed to continuously maintain the facility's roofing system in accordance with NFPA 101 (2012 Edition)

The findings included:

On 06/02/2021 between 9:30 AM and 11:30 AM, during record review and a facility tour with DOM, it was observed that the Laundry room ceiling tile in the back corner had stained markings. Further investigation, revealed that a roof leak for that location was reported in February 2021. On May 26, 2021, the facility had a vendor evaluate the scope of work for the leak. The vendor submitted a quote during that service call that stated the roof panels in that location had loose and missing screws. The entire valley edges; where panels meet valley metal; all laps in the roof valley overlays and all screw heads in the assembly need polyurethane sealing. In an interview, the DOM said the facility had not repaired the leaking roof system at the time of the visit.

Photograph(s) of the evidence presented in the file.
Photos will serve as supplemental information only.

per NFPA 101 (2012 Edition) Chapter(s)