HospitalInspections.org

K355 - Portable Fire Extinguishers
Findings:
The surveyor observed, while accompanied by the CEO and Director of Quality & Risk Management, during the hours of the survey from 4:30 pm to 6:30 pm on 07/29/2025 and 7:30 am - 9 am on 07/30/2025, that there were the following issues:

1) Based on observations during the tour, fire extinguisher no. 16 located in Maintenance area had a pressure gauge indicator needle that was pointed in the overcharged zone.

K712 - Fire Drills
Findings:
The surveyor observed, while accompanied by the CEO and Director of Quality & Risk Management, during the hours of the survey from 4:30 pm to 6:30 pm on 07/29/2025 and 7:30 am - 9 am on 07/30/2025, that there were the following issues:

1) Based on review of the records, facility failed to perform fire drills at unexpected times, at least quarterly on each shift. For instance, for the year 2025, majority of drills were conducted during 1st shift between 7 am - 7 pm. The records failed to document whether drills included the transmission of a fire alarm signal.
2) Fire drill participation form evaluation assessment could be improved for readability and comprehension.

K907 Gas and Vacuum Piped Systems - Maintenance Program

Findings:
The surveyor observed, while accompanied by the CEO and Director of Quality & Risk Management, during the hours of the survey from 4:30 pm to 6:30 pm on 07/29/2025 and 7:30 am - 9 am on 07/30/2025, that there were the following issues:

1) Based on observations in Vacuum Pump Room, the vacuum pipe support Clevis hanger type all thread was separated from its saddle.

K914 - Electrical Systems - Maintenance and Testing

Findings:
The surveyor observed, while accompanied by the CEO and Director of Quality & Risk Management, during the hours of the survey from 4:30 pm to 6:30 pm on 07/29/2025 and 7:30 am - 9 am on 07/30/2025, that there were the following issues:

1) Based on review of the records, facility did not perform any receptacle maintenance and testing at all in patient care areas. NFPA 99-2012, section 6.3.3.2 lists the minimum requirements for receptacle testing regardless of hospital-grade or not. Describe the facility justification of testing frequency (e.g. appropriate testing intervals) based on documented performance data. For example, experiential data shows that retention force of the grounding blade of each electrical receptacle decreases over time due to repeated usage. Thus, the failure rate has a direct correlation to time and usage.