HospitalInspections.org

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Based on observation and interview, the facility failed to maintain the means of egress per the requirements of:

2012 NFPA 101, 19.2.3.4 (4) (c)

This deficiency could affect 22 patients.

Findings include:

On 07/31/2018, during a tour of the facility from 9:00 am to 3:30 pm, the surveyor observed the egress corridor near the Nurses' Station was obstructed by a crash cart, two blood pressure stands on wheels, and one oxygen concentrator.

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 illumination for the means of egress per the requirements of:

2012 NFPA 101, 19.2.8, and 7.8.1.2

Findings include:

On 7/31/2018, during a tour of the facility from 9:00 am to 3:30 pm, the surveyor observed an exit discharge lighting fixture was not illuminated for the front exit of the facility.

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 LS Survey.

Based on observation and interview, the facility failed to provide separation for hazardous areas per the requirements of:

2012 NFPA 101, 19.3.2.1.3

Findings include:

On 07/31/2018, during a tour of the facility from 9:00 am to 3:30 pm, the surveyor observed Storage Room #118 was over 50 sq. ft. and had combustible materials (files and boxes); the door was observed without a self-closing device.

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 automatic fire-extinguishing system for the dietary hood per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 10.2.6 (4)
2009 NFPA 17A, 7.2.2 (1-8)

Findings include:

On 07/31/2018, during a tour of the facility from 9:00 am to 3:30 pm, the facility failed to provide documentation of conducting monthly inspections on the automatic fire-extinguishing system for the dietary hood; the card attached to the automatic fire-extinguishing system for the dietary hood was blank for the monthly inspections. This system was last serviced on 2/19/2018.

A member of maintenance staff was present when this deficiency was found.

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Based on observation and interview, the facility failed to maintain the fire alarm system communication (phone line) per the requirements of:

2012 NFPA 101, 19.3.4.3.2.1, and 9.6.1.3
2010 NFPA 72, 26.6.3.2.1.4 (B) (3)

Findings include:

On 07/31/2018, during a tour of the facility from 9:00 am to 3:30 pm, the surveyor observed the fire alarm system phone line 1 failed to give a trouble signal within the required 4 minutes. The surveyor waited 6 minutes and a trouble signal was not received.

A member of the maintenance staff was present when the deficiency was identified.
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This tag is a rewrite from last LS Survey.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system per requirements of:

2012 NFPA 19.3.5.1, and 9.7.1.1
2010 NFPA 13 8.6.4.1.2 (4)

Findings include:

On 07/31/2018, during a tour of the facility from 9:00 am to 3:30 pm, the surveyor observed the ceiling sagging down and laying on top of the upright sprinkler head in the Lab.; obstructing the head's spray pattern.

A member of the maintenance staff and administrator was present, when this deficiency was identified.
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This tag is a rewrite from last LS Survey.

Based on observation, review of documentation and interview, the facility failed to maintain the automatic sprinkler system per requirements of:

2012 NFPA 19.3.5.1, and 9.7.5
2011 NFPA 25, 5.3.1.1.1, 5.3.1.1.1.3, 5.2.4.2, 5.3.2.1

Findings include:

On 07/31/2018, during a tour of the facility from 9:00 am to 3:30 pm,:
1. The facility failed to provide documentation that a representative sample of the fast-response/solder type sprinklers had been tested or replaced since installation. These sprinklers were installed in 1993/1963.

2. The facility failed to provide documentation of weekly inspections on the dry automatic sprinkler riser gauges.

3. The facility failed to provide documentation the automatic sprinkler system wet riser gauges had been calibrated or replaced within the past 5 years. The gauges were installed in 2012 per interview and documentation.

A member of the maintenance staff and administrator was present, when this deficiency was identified.
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This tag is a rewrite from last LS Survey.

Based on observation and interview, the facility failed to maintain a fire extinguisher per the requirements of:

2012 NFPA 19.3.5.12, and 9.7.4.1
2010 NFPA 10 6.1.2

Findings include:

On 07/31/2018, during a tour of the facility from 9:00 am to 3:30 pm, the surveyor observed a fire extinguisher with it's gauge reading on the recharge side in the corridor by the X-Ray Room.

A member of maintenance staff was present when this deficiency was found.
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This tag is a rewrite from last LS Survey.

Based on observation and interview, the facility failed to maintain a corridor door to resist the passage of smoke per the requirements of:

2012 NFPA 101, 19.3.6.3.2 (2)

Findings include:

On 07/31/2018, during a tour of the facility from 9:00 am to 3:30 pm, the surveyor observed the corridor door for the X-Ray Room had an approximately 1/4" gap when the door was fully closed in the frame.

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 provide an HVAC system per the requirements of:

2012 NFPA 101, 19.5.2.1, and 9.2.1
2012 NFPA 90A, 4.3.12.1.1

This deficiency could affect all residents.

Findings include:

On 07/31/2018, during a tour of the facility from 8:00 am to 3:30 pm, the corridors were observed being used as return air plenums for the HVAC.

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 conduct fire drills per the requirements of:

2012 NFPA 101, 19.7.1.6

This deficiency could affect all residents.

Findings include:

On 07/31/2018, during a review of documentation from 9:00 pm to 3:30 pm, the facility provided the following documentation for conducting fire drills:
First Shift (7 am - 7 pm)
07/07/2018 - 6:30 am
04/27/2018 - 5:30 am
01/17/2018 - 8:45 am
10/08/2017 - 7:00 am

Second Shift (7 pm - 7 am)
05/11/2018 - 8:30 am
02/13/2018 - 5:00 am
11/07/2017 - 9:00 am
08/24/2017 - 6:45 am

A member of the maintenance staff and administrator 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 the cubical curtains being flame retardant per the requirements of:

2012 NFPA 101, 19.7.5.1, and 10.3.1

Findings include:

On 07/31/2018, during a review of documentation from 9:00 am to 3:30 pm, the facility failed to provide documentation on the fire rating of the cubical curtains.

A member of the maintenance staff and administrator 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, 6.4.4.1.1.3
2010 NFPA 110, 8.3.8 and 8.4.2.3

Findings include:

On 07/31/2018, during a tour of the facility from 9:00 am to 3:30 pm, the facility failed to provide the following documentation:

1. Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

2. To have a fuel quality test performed at least annually using tests approved by ASTM standards.

A member of the maintenance staff was present when this deficiency was identified.
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This tag is a rewrite from last LS Survey.

Based on observation and interview, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.2.3 (11)

On 07/31/2018, during a tour of the facility from 9:00 am to 3:30 pm, the surveyor observed four unsecured oxygen cylinders in the Outside Storage Area's full side.

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