HospitalInspections.org

Based on document review and staff interview, it was determined the facility failed to ensure that cooking equipment was protected in accordance with NFPA (National Fire Protection Association) 96. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Document review on 11/15/22 at approximately 11:08 a.m. revealed the kitchen range hood had been inspected on 11/11/21 and 7/1/22, but no documentation was available for review to show that the kitchen range hood had been inspected semi-annually during the 1st half of 2022.

Interview on 11/15/22 at approximately 11:09 a.m. with the Director of Plant Operations verified this finding. This finding was also acknowledged by the Executive Director at the exit interview on 11/15/22 at approximately 3:53 p.m.

Based on observation and staff interview, it was determined the facility failed to ensure that automatic sprinkler and standpipe systems were maintained in accordance with NFPA (National Fire Protection Association) 25. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Observation on 11/14/22 at approximately 1:41 p.m. revealed rusty sprinkler escutcheons throughout the Dish Room in the Kitchen.

Interview on 11/14/22 at approximately 1:42 p.m. with the Director of Plant Operations verified this finding. This finding was also acknowledged by the Executive Director at the exit interview on 11/15/22 at approximately 3:53 p.m.

Based on observation and staff interview, it was determined the facility failed to ensure that portable fire extinguishers were installed and maintained in accordance with NFPA (National Fire Protection Association) 10. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Observation on 11/14/22 at approximately 1:09 p.m. revealed the Class K fire extinguisher located in the Kitchen, near the walk-in cooler, which had not been inspected monthly since 09/29/22.

Observation on 11/14/22 at approximately 1:12 p.m. revealed a fire extinguisher located in the Kitchen, near the Dry Storage Area, which had not been inspected monthly since 08/29/22.

Observation on 11/14/22 at approximately 2:10 p.m. revealed a fire extinguisher located in the clean side of Laundry, which had not been inspected monthly since 08/29/22.

Interview on 11/14/22 at approximately 2:11 p.m. with the Director of Plant Operations verified these findings. The findings were also acknowledged by the Executive Director at the exit interview on 11/15/22 at approximately 3:53 p.m.

Based on observation and staff interview, it was determined the facility failed to ensure that smoke and fire barriers were constructed and maintained to the appropriate fire resistance rating in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Observation on 11/15/22 at approximately 1:43 p.m. revealed an approximately three (3) inch by six (6) inch penetration from an abandoned junction box in the interstitial space of the 400 Corridor on the Acute Rehabilitation Unit, which penetrated the stairwell wall near the Day Room.

Observation on 11/15/22 at approximately 1:58 p.m. revealed the two (2) hour rated fire barrier separation between the Acute Rehabilitation Unit and the Long Term Care Unit had unsealed penetrations around piping and along the top of the separation wall between Room 409 and the Shower Room.

Interview on 11/15/22 at approximately 1:59 p.m. with the Director of Plant Operations verified these findings. The findings were also acknowledged by the Executive Director at the exit interview on 11/15/22 at approximately 3:53 p.m.

Based on document review and staff interview, it was determined the facility failed to ensure that fire drills were held at least quarterly on each shift in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Document review on 11/15/22 at approximately 11:42 a.m. revealed no documentation of a fire drill being conducted on the 1st Shift (7:00 a.m. to 3:00 p.m.) of the 3rd Quarter of 2022.

Interview on 11/15/22 at approximately 11:43 a.m. with the Director of Plant Operations verified this finding. This finding was also acknowledged by the Executive Director at the exit interview on 11/15/22 at approximately 3:53 p.m.

Based on observation and staff interview, it was determined the facility failed to ensure that portable space heaters were not used in patient care areas in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Observation on 11/14/22 at approximately 2:53 p.m. revealed an oil filled space heater being used in the Physical Therapy Department in the Basement.

Interview on 11/14/22 at approximately 2:54 p.m. with the Director of Plant Operations verified this finding. This finding was also acknowledged by the Executive Director at the exit interview on 11/15/22 at approximately 3:53 p.m.

Based on document review and staff interview, it was determined the facility failed to maintain and test electrical receptacles at patient bed locations in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Document review on 11/15/22 at approximately 11:53 a.m. revealed no documentation that additional testing was performed at intervals defined by documented performance data for hospital-grade receptacles at the patient bed locations for Room 401, Rooms 403-408, and Rooms 410-411 on the Acute Rehabilitation Unit.

Interview on 11/15/22 at approximately 11:54 a.m. with the Director of Plant Operations verified this finding. This finding was also acknowledged by the Executive Director at the exit interview on 11/15/22 at approximately 3:53 p.m.

Based on document review and staff interview, it was determined the facility failed to ensure that maintenance and testing of the generator and transfer switches was performed in accordance with NFPA (National Fire Protection Association) 110. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 7.

Findings include:

Document review on 11/15/22 at approximately 11:31 a.m. revealed the annual fuel quality test for the emergency generator had been completed on 05/11/22 and received a failing test result. No documentation was available for review to show that the fuel quality had been treated and retested to achieve a passing test.

Interview on 11/15/22 at approximately 11:32 a.m. with the Director of Plant Operations verified this finding. This finding was also acknowledged by the Executive Director at the exit interview on 11/15/22 at approximately 3:53 p.m.