HospitalInspections.org

Based on review of the Irwin County Hospital Emergency Preparedness Program and interviews with staff it was determined that the facilities plan was not in substantial compliance set forth in Appendix Z.
This could place all residents at risk in the event of an emergency
The findings include:
During a review of the facilities Emergency Preparedness Program on 04/08/2025 between 9:30 am and 1:00 pm it was noted that the facility did not provide two exercises, therefore the facilities emergency prepardness program did not meet the requirements of Appendix Z.
These findings were confirmed by Staff M at the time of discovery.

Based on observation, and staff interviews it was determined the facility failed to ensure that the means of egress was not blocked
This could affect patients and staff near and in the OR.
The findings include:
During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that the exterior side of the exit door is blocked.
These findings were confirmed by Staff M at the time of discovery.
Reference:2012 NFPA 101, Chapter 19, Section 19.2.1 and Chapter 7, Section 7.1.10.2.1

Based on observation, and staff interviews it was determined the facility failed to ensure emergency lights were operational.
This affects the CT area.
The findings include:
During a tour of the facility with Staff M on 04/08/2025 between 09:30 AM and 1:00 PM observation revealed that the emergency lights were not operational .
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101, 19.2.9.1, 7.9.1, 7.9.2

Based on observation, and staff interviews it was determined the facility failed to ensure exit signs are operational This affects the Radiology office
The findings include:
During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that the exit sign was not properly working at radiology.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101, 19.2.10.1, 7.10.5.1

Based on observation, review of facility records, and staff interviews it was determined the facility failed to get proper maintenance and cleaning completed on kitchen hood suppression systems.
This affects the kitchen
The findings include:
During a tour of the facility with Staff M on 04/08/2025 between 09:30 AM and 1:00 PM observation revealed that that the hood suppression system is due for service and cleaning, last service and cleaning was completed in September of 2024.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101 Chapter 19, Section 19.3.2.5.1 and Chapter 9, Section 9.2.3, and 2011 NFPA 96 Chapter 11, Section 11.2.1, 11.4, 11.5

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure smoke detector was properly mounted to the ceiling.
This affects the kitchen pantry.
The findings include:
During a tour of the facility with Staff M on 04/08/2025 between 09:30 AM and 1:00 PM observation revealed that the smoke detector in the kitchen pantry was hanging down from its mount.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101, Chapter 19, Section 19.3.4.1 and Chapter 9, Section 9.6.1.8.1

1. Based on observation, and staff interviews it was determined the facility failed to ensure ceiling tiles were properly placed.
This affects all patients and staff in facility
The findings include:
During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that ceiling tiles were missing These findings were confirmed by Staff M at the time of discovery.
Reference: : 2012 NFPA 101, Chapter 19, Section 19.3.5.1, Chapter 9, Section 9.7.1.1.(1) and 2010 NFPA 13, Chapter 8, Section 8.5.4.1.1.

2.Based on observation, and staff interviews it was determined the facility failed to ensure wires were not being supported by the sprinkler piping.
This affects all patients and staff in facility
The findings include:
During a tour of the facility with Staff M on 04/08/2025 between 09:30 AM and 1:00 PM observation revealed that electrical wires were being supported by sprinkler pipes on the main hall and OR entrance.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101, Chapter 19 Sections 19.1.1.1.3, 19.3.5, 19.3.5.1, Chapter 9, Section 9.7.1.1, 9.7.5, Chapter 4, Section 4.6.12.1 2011 NFPA 25, Chapter 5, Section 5.2.2.2, 2010 NFPA 13, 9.1.1.7

3.Based on observation, and staff interviews it was determined the facility failed to ensure sprinkler systems were properly cleaned throughout the facility.
This affects all patients and staff in facility
The findings include:
During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that sprinkler heads had dust covering the fusible link These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101, Chapter 19, Section 19.3.5.1, 19.1.1.1.3, 4.6.12.1, 9.7.5 and 2011 NFPA 25, Chapter 5, Section 5.2.1.1.2, 5.2.1.1.4

4.Based on observation, and staff interviews it was determined the facility failed to ensure that escutcheon rings were not missing.
This affects all patients and staff in facility
The findings include:
During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that escutcheon rings were missing from the sprinkler assembly These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101, Chapter 19, Sections 19.1.6.1, 19.3.5.1, 19.3.5.3, 19.3.5.4, Chapter 9, Sections, 9.7.5, 9.7.6, 9.7.1.1 and 2011 NFPA 25. Chapter 5, Sections; 5.2.1.1.2 & 5.2.1.1.4, (explanation in Annex E, E.1, Table E.1), and 2010 NFPA 13, Chapter 6, Section 6.2.7

5.Based on observation, and staff interviews it was determined the facility failed to ensure the fire suppresion system is fully operational with no deficiencys.
This affects all patients and staff in facility
The findings include:
During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that the fire suppression system has been yellow tagged These findings were confirmed by Staff M at the time of discovery.
Reference:2012 NFPA 101,19.3.5.1, 9.7.1.1, 9.7.5, 9.7.7, 9.7.8, 4.6.12.1, 2011 NFPA 25, 4.1.4.1

6.Based on observation, and staff interviews it was determined the facility failed to ensure the gauges on the fire suppression system were up to date.
This affects all patients and staff in facility
The findings include:
During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that the fire suppression system gauges were out of date These findings were confirmed by Staff M at the time of discovery.
Reference:2012 NFPA 101, 19.1.1.1.3, 19.1.6.1, 19.3.5.4, 9.7.1, 2011 NFPA 25, 5.3.2.1

Based on observation, and staff interviews it was determined the facility failed to ensure fire caulk was not mixed while closing penetrations This affects the respriatory therapy area
The findings include:
During a tour of the facility with Staff M on 04/08/2025 between 09:30 AM and 1:00 PM observation revealed that fire caulk was mixed when it was applied to fill a penetration.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101, 19.3.7.1, 19.3.7.3, 8.3.5, 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2, 8.5.6.3, 4.6.12.1

Based on observation, and staff interviews it was determined the facility failed to ensure continuity of fire walls
This affects main hall, fire wall near room 101, and fire wall near the OR entrance.
The findings include:
During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that there are multiple penetrations and or unsealed openings.
These findings were confirmed by Staff M at the time of discovery.
Reference:2012 NFPA 101 , Chapter 19, Sections 19.3.7.1, 19.3.7.3, Chapter 8 Sections 8.3.5, 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2, 8.5.6.3, Chapter 4, Section 4.6.12.1

1. Based on observation, and staff interviews it was determined the facility failed to ensure that junction boxes are properly secured
This affects main hall and the OR entrance.
The findings include:
During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that there are open junction boxes in the main hall and OR entrance.
These findings were confirmed by Staff M at the time of discovery.
Reference:2012 NFPA 101 Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70 Article 314.28 (C) and 110.27

2. Based on observation, and staff interviews it was determined the facility failed to ensure proper instillation and mainenance of electrical equipment
This affects the kitchen and radiology
The findings include:
During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation revealed that there were open spaces left in the electrical panels.
These findings were confirmed by Staff M at the time of discovery.
Reference:2012 NFPA 101, Chapter 19, Sectin 19.5.1.1, Chapter 9, Section 9.1.2 and 2011 NFPA 70, Article 408.7

Based on observation, review of facility records, and staff interviews it was determined the facility failed to insure proper testing and maintenance of fire doors.
This could affect all patients and staff of the facility
The findings include:
During a tour of the facility with Staff M on 04/08/2025 between 9:30 AM and 1:00 PM observation review and interviews revealed that required testing has not been conducted or documented.
These findings were confirmed by Staff M at the time of discovery.
Reference: 2012 NFPA 101, 19.7.6, 8.3.3.1, 2010 NFPA 80, 5.2, 5.2.3, CMS S&C 17-38-LSC