HospitalInspections.org

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Based on observation and interview, the facility failed to provide a complete automatic sprinkler system required for the building construction types per the requirements of:

2012 NFPA 101, 19.1.6.1, and Table 19.1.6.1

This deficiency could affect approximately 20 occupants.

Findings include:

On 12/04/2019, during a tour of the facility from 8:00 am to 2:30 pm, the surveyor observed the Kitchen walk-in cooler and walk-in freezer did not have automatic sprinkler coverage.

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 corridor means of egress per the requirements of:

2012 NFPA 101, 19.2.3.4 (2)
S&C-10-18-LSC

This deficiency could affect approximately 25 occupants.

Findings include:

On 11/05/2019, during a tour of the facility from 8:00 am to 2:30 pm, the surveyor observed wall-mounted Chart Stations on patient corridors projected approximately 12 inches into the corridor. There was approximatly 10 to 12 of these stations.

A member of maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain the hazardous rooms per the requirements of:

2012 NFPA 101, 19.3.2.1.2, and 19.3.2.1.3

This deficiency could affect approximately 15 occupants.

Findings include:

On 12/04/2019, during a tour of the facility from 9:30 am to 3:30 pm, the surveyor observed the following unsealed penetrations through the1hour concrete block wall located in Boiler Room Three:
1. An 1/2" EMT conduit
2. An 3/8" MC cable

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, interview and review of documentation, the facility failed to maintain the kitchen hoods per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 10.2.6 (4), 6.1.1, and 10.2.8
2009 NFPA 17A, 7.2.1, and 7.2.2

This deficiency could affect approximately 25 occupants.

Findings include:

1. On 12/03/2019, during a tour of the facility from 9:30 am to 3:30 pm, the facility failed to provide the monthly inspections for the Snack Bar (at the serving line) kitchen hood's automatic fire-extinguishing system.
2. On 12/03/2019, during a tour of the facility from 9:30 am to 3:30 pm, the surveyor could not verify the type of grease removal system used in the main Kitchen's hood and if the cleaning process for this hood was appropriate or not. No filters were observed and based on design and the surveyor's knowledge the hood could have a water wash system. The facility could not provide any documentation nor did the facility have knowledge of what type of system was in place for this hood.

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

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Based on observation and interview, the facility failed to provide ceilings required for the pendant sprinklers in the facility per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.1.1 (1)
2010 NFPA 13, 8.5.1.1, 8.5.1.2, 8.5.4.2, 6.2.7.1, and 6.2.7.2

This deficiency could affect approximately 20 occupants.

Findings include:

On 12/03/2019, during a tour of the facility from 9:30 am to 3:30 pm, the surveyor observed the following:
1. A broken ceiling tile leaving an approximately one foot opening through the ceiling in the Human Resourses File Room
2. Three recessed sprinkler heads were missing their escutcheons leaving an approximately 1" gap around each in the Radiology corridor.

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 maintain the automatic sprinkler system per requirements of:

2012 NFPA 101, 9.7.5
2011 NFPA 25, 5.2.4.1

This deficiency could affect approximately 50 occupants.

Findings include:

On 11/05/2019, during a tour of the facility from 8:00 am to 2:30 pm, the facility failed to provide documentation of the monthly inspections on the wet sprinkler riser gauges.

A member of the maintenance staff was present when this deficiency was identified.
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41792

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

2012 NFPA 101, 9.7.5
2011 NFPA 25, 5.3.4

This deficiency could affect approximately 15 occupants.

Findings include:

On 12/04/2019, during a tour of the facility from 8:00 am to 2:30 pm, the facility failed to provide documentation on the annual inspections of the anti-freeze sprinkler system located outside at the Emergency Room/Ambulance drop off. The last annual inspection documented on the tag was 03/19/2018.

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 portable fire extinguishers per the requirements of:

2012 NFPA 101, 19.3.5.12, and 9.7.4.1
2010 NFPA 10, 7.2.1.2, 7.2.2, 6.1.3.8.3, and 6.1.3.4

This deficiency could affect approximately 10 occupants.

Findings include:

On 11/05/2019, during a tour of the facility from 8:00 am to 2:30 pm, the surveyors observed the following:
1. The fire extinguisher in the X-ray File Room
a. The last annual inspection was 04/2018
b. The last monthly inspection was 04/2019


41792


2. The last monthly inspection for the fire extinguisher in the Wing 2 Boiler Room was October 2019
3. A fire extinguisher was setting on the floor in the Wing 2 Boiler Room

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

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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), and 19.3.6.3.5
S&C-07-18
42 CFR 482.41 (b) (1) (ii)

This deficiency could affect approximately 30 occupants.

Findings include:

On 11/05/2019, during a tour of the facility from 8:00 am to 2:30 pm, the surveyors observed the following:
1. The Med Surge Employee Stock Room's corridor door had two unsealed 1/2" holes around the door handle.


41792


2. The Human Resources Storage Closet corridor door
a. Had a roller latch
b. Had an approximately 3/8" gap around the top of the dead bolt
3. The Social/Mental Health Office corridor door had a roller latch

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 smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, and 8.5.6.3

This deficiency could affect approximately 70 occupants.

Findings include:

On 12/04/2019, during a tour of the facility from 9:30 am to 3:30 pm, the surveyor observed the following above the ceiling throughout building, examples are:
1. Two ½" conduits in the smoke barrier at the Cafeteria:
a. The ends were unsealed
b. Around the conduits was a non-approved foam sealant
2. The smoke barrier at Radiology:
a. Had several unsealed penetrations
b. Non-approved foam sealant
3. The smoke barrier at the Lobby corridor had an unsealed 3/4 "conduit

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 electrical wiring and equipment per the requirements of:

2012 NFPA 101, 19.5.1.1, and 9.1.2
2011 NFPA 70, 408.7, and 314.28(3)(C)

This deficiency could affect approximately 5 occupants.

Findings include:

On 12/03/2019, during a tour of the facility from 9:30 am to 3:30 pm, the surveyor observed the following:
1. An unused opening for a circuit breaker in the electrical panel labeled "B.E.S." in Wing Three Boiler Room
2. A 4" x 4" electrical junction box located above the ceiling by the Mechanical Room at the Front Lobby was missing its cover

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, 4.7.2, and 4.7.4

This deficiency could affect approximately all occupants.

Findings include:

On 12/04/2019, during a tour of the facility from 8:00 am to 2:30 pm, the facility provided the following documentation:
First Shift
11/20/2019 - 9:31 am
07/15/2019 - 9:30 am
04/30/2019 - 11:05 am
01/09/2019 - 10:30 am

The First Shift fire drills were all conducted within 1 hour and 35 minutes for the 8 hour shift for the whole year.

Second Shift
10/31/2019 - 4:21 pm
08/02/2019 - 10:06 pm
05/23/2019 - 9:50 pm
02/18/2019 - 10:46 pm

Third Shift
09/30/2019 - 2:46 am
06/27/2019 - 6:47 am
03/08/2019 - 2:20 am
12/26/2018 - 2:05 am

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 designated smoking area per the requirements of:

2012 NFPA 101, 19.7.4 (6)

This deficiency could affect approximately 10 occupants.

Findings include:

On 12/04/2019, during a tour of the facility from 8:00 am to 2:30 pm, the surveyor observed the Wing One designated smoking area did not have a metal container with self-closing cover 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 prohibit a portable space heating device per the requirements of:

2012 NFPA 101, 19.7.8

This deficiency could affect approximately 15 occupants.

Findings include:

On 12/04/2019, during a tour of the facility from 8:00 am to 2:30 pm, the surveyor observed a portable space heating device that was plugged in and located under the wood desk in the Pharmacy Department. The facility was unable to provide documentation on the heating element not exceeding 212 degrees.

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 emergency generator's remote annunciator per the requirements of:

2012 NFPA 99, 6.4.1.1.17 (1) (a)

This deficiency could affect approximately 75 occupants.

Findings include:

On 12/04/2019, during a tour of the facility from 9:30 am to 3:30 pm, the surveyor observed Generator #1 that was installed in 2012 did not have a remote annunciator.

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 maintain the diesel generator's fuel per the requirements of:

2012 NFPA 99, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, and 8.3.8

This deficiency could affect all occupants.

Findings include:

On 12/04/2019, during a tour of the facility from 9:30 am to 3:30 pm, the facility failed to provide documentation that a fuel quality test was performed within the past twelve months using tests approved by ASTM standards for both generators.

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 electrical equipment per the requirements of:

2012 NFPA 99, 10.2.3.6, and 10.2.4
2011 NFPA 70, 400.8
S&C: 14-46-LSC

This deficiency could affect approximately 10 occupants.

Findings include:

On 12/05/2019, during a tour of the facility from 8:00 am to 2:30 pm, the surveyor observed a laptop computer in the Physical Therapy Office was plugged into a blue extension cord that was plugged in an outlet in the adjacent office.

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 oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.5.1, 11.6.5.2, and 11.6.5.3

This deficiency could affect approximately 15 occupants.

Findings include:

On 12/04/2019, during a tour of the facility from 8:00 am to 2:30 pm, the surveyor observed medical gas cylinders stored and not segregated or marked to avoid confusion in the following locations:
1. Two M250 oxygen cylinders (approximately 300 cu. ft.) in the Med. Gas Storage Room at the loading dock of the Kitchen/Laundry Area
2. Two M250 nitrous oxide cylinders (approximately 300 cu. ft.) in the Wing Three Boiler Room/Gas Storage and Regulator Room

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 oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.2.3 (11)

This deficiency could affect approximately 15 occupants.

Findings include:

On 12/03/2019, during a tour of the facility from 9:30 am to 3:30 pm, the surveyor observed unsecured med. gas cylinders in the following locations:
1. Two M250 nitrous oxide cylinders (approximately 300 cu. ft.) in the Wing Three Boiler Room/Gas Storage and Regulator Room
2. One M6 oxygen cylinder (approximately 6 cu. ft.) in the Med. Gas Storage Room at the loading dock of the Kitchen/Laundry Area

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