HospitalInspections.org

Based on documentation review and interview, it was determined the facility failed to provide an EM plan to include the use of volunteers in an emergency.

Findings include:

1. Review of documentation on August 6, 2019, at 1:25 p.m., revealed the facility lacked a plan to include the use of volunteers in an emergency.

Exit interview with the facility representative #1 on August 6, 2019, at 2:00 p.m., confirmed the lack of documentation.

Based on documentation review and interview, it was determined the facility failed to provide a plan to share information and medical documentation for patients.

Findings include:

1. Review of documentation on August 6, 2019, at 1:25 p.m., revealed the facility lacked a plan to share information and medical documentation for patients.

Exit interview with the facility representative #1 on August 6, 2019, at 2:00 p.m., confirmed the lack of documentation.

Based on observation and interview, it was determined the following item(s) did not meet the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component.

Findings include:

1. Observation on August 6, 2019, at 9:15 a.m., revealed the facility failed to supply the required portable, accurate floor plans identifying smoke barrier walls, fire walls, shafts, hazardous areas, exits, etc. for the Life Safety Survey.

Exit interview with the facility representative #1 on August 6, 2019, at 2:00 p.m., confirmed the facility did not have accurate floor plans.

Based on observation and interview, it was determined the facility failed to maintain means of egress in two instances within the facility.

Findings include:

1. Observation on August 6, 2019, between 11:30 a.m. and 12:20 p.m., revealed:

a. 11:30 a.m. - The basement-level exit door located at the Central Skilled exit needed excessive force to be opened.

b. 12:20 p.m. - The corridor between the Main Lobby and Skilled had reduced width due to vending machines.

Exit interview with the facility representative #1 on August 6, 2019, at 2:00 p.m., confirmed the exit door needed excessive force to be opened and egress obstruction.

Based on observation and interview, it was determined the facility failed to maintain exit stair towers in one instance within the facility.

Findings include:

1. Observation on August 6, 2019, at 10:30 a.m., revealed the Main Lobby stair door to the basement could not close and latch when released from the hold open magnet.

Exit interview with the facility representative #1 on August 6, 2019, at 2:00 p.m., confirmed the door could not close and latch.

Based on observation and interview, it was determined the facility failed to maintain the exit discharge in one instance within the facility.

Findings include:

1. Observation on August 6, 2019, at 12:10 p.m., revealed the basement level exit discharge leads into a landscaped area of uneven ground which is mulch and plants.

Exit interview with the facility representative #1 on August 6, 2019, at 2:00 p.m., confirmed the exit discharge.

Based on observation and interview, it was determined the facility failed to maintain hazardous areas in one instance within the facility.

Findings include:

1. Observation on August 6, 2019, at 12:50 p.m., revealed the basement level, mechanical room #6 lacked a self-closing device.

Exit interview with the facility representative #1 on August 6, 2019, at 2:00 p.m., confirmed the lack of a self-closing device.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in two instances within the facility.

Findings include:

1. Observation on August 6, 2019, between 10:10 a.m. and 12:45 p.m. revealed:

a. 10:10 a.m. - The smoke barrier doors located near the 1st floor Med Surge Conference room could not close completely when released from the hold open devices.

b. 12:45 p.m. - The smoke barrier doors located near the basement level Physical Therapy room could not close completely when released from the hold open devices.

Exit interview with the facility representative #1 on August 6, 2019, at 2:00 p.m., confirmed the doors could not close.

Based on document review and interview, the facility failed to maintain electrical receptacles affecting the entire facility.

Findings include:

1. Review of documentation on August 6, 2019, at 9:30 a.m., revealed the facility lacked documentation for a required annual electrical receptacle inspection (non-hospital grade receptacles only).

Exit interview with the facility representative #1 on August 6, 2019, at 2:00 p.m., confirmed the lack of documentation.

Based on observation and interview it was determined the facility failed to maintain electrical wiring and equipment in one instance within the facility.

Findings include:

1. Observation on August 6, 2019, at 12:55 a.m., revealed the basement level Drug Testing room had a surge protector in use for a microwave.

Exit interview with the facility representative #1 on August 6, 2019, at 2:00 p.m., confirmed the unauthorized surge protector.