HospitalInspections.org
Bringing transparency to federal inspections
UW HEALTH REHABILITATION HOSPITAL
Sprinkler System - Installation
Tag No.: K0351
Based on observation and interview, the facility did not provide a sprinkler system with no obstructions near the sprinkler head in accordance with NFPA 101 (2012 ed.), 19.3.5.1 and NFPA 13 (2010 ed.), 8.6.5.2.1.1 (Table 8.6.5.1.2), 8.6.5.2.2 and 8.6.5.2.2.1. These deficiencies had the potential to affect an undetermined number of inpatients, staffs and visitors.
FINDINGS INCLUDE:
1. On 4/23/2018 at 3:15 PM, observation revealed on the first floor in the transfer therapy shower room, that a shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to other side of the curtain.
2. On 4/23/2018 at 3:35 PM, observation revealed on the first floor in the ADL suite bathroom, that a shower curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the other side of the curtain.
Thees deficient practices were confirmed by Staff A (Plant Manager), Staff B (Maintenance) and Staff G (Director, Plant Operations) at the time of discovery.
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on observation and interview the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 19.3.5 and 9.7.5, and NFPA 25 - 2011 edition, Sections 5.2.1, and 5.2.1.1.1. This deficiency had the potential to affect an undetermined number of inpatients, staffs and visitors.
Findings include:
On 4/23/2018 at 2:50 PM, observation revealed in the first floor kitchen freezer that the sprinkler head had lint and other foreign materials on it.
This deficient practice was confirmed by Staff A (Plant Manager), Staff B (Maintenance) and Staff G (Director, Plant Operations) at the time of discovery.
Electrical Systems - Essential Electric Syste
Tag No.: K0918
Based on interview and record review, the facility failed to maintain the emergency electrical generator in accordance with the requirements of NFPA 101 - 2012 edition, Sections 9.1.3.1; NFPA 110 - 2010 edition, Sections 5.3.1 and 8.4.1. This deficiency had the potential to affect an undetermined number of inpatients, staffs and visitors.
FINDINGS INCLUDE:
On 4/23/2018 at 1:45 PM, during the review of facility generator maintenance documents it was revealed that the heater for the jacket water and lube oil of the emergency generator were not inspected monthly within the last year.
This deficient practice was confirmed by Staff A (Plant Manager), Staff B (Maintenance) and Staff G (Director, Plant Operations) at the time of discovery.