HospitalInspections.org

Based on observation, the facility failed to ensure means of egress were continuously maintained free of all obstructions or impediments to full instant use in case of emergency in accordance with NFPA 101, 2012 Edition, Section 7.1.10.1. This deficiency affects 1 of 2 smoke compartments.

Findings include:

1. During an observation on 8/16/17 at 8:40 a.m., exiting out of the east wing onto the sidewalk a plastic lawn couch was positioned on the sidewalk in the path to the public way.

Based on observation, the facility failed to ensure the sign indicating the exit was delayed egress had letters not less than one inch with placement on the door leaf adjacent to the releasing device in accordance with NFPA 101, 2012 Edition, Section 7.2.1.6.1.1(4). This deficiency affects 1 of 2 smoke compartments.

Findings include:

1. During an observation on 8/16/17 at 9:37 a.m., the sign for delayed egress for the west wing exit was located a foot to the right of the egress door on the west wing. The letters measured seven sixteenth of an inch high.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8). This deficiency affects 1 of 2 smoke compartments.

Findings include:

1. During an observation on 8/16/17 at 9:10 a.m., in the clinic lobby an ABHR was installed over the light switch in the room.

Based on record review, the facility failed to have specific evidence of the five year obstruction testing in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 14.2.1. This deficiency has the potential to affect the entire facility.

Findings include:

1. Review of the quarterly sprinkler inspections dated 4/5/17, 2/23/17, 10/4/16, and 9/16/16 showed "Has piping been internally inspected in last 5 years." The "yes" was circled.

In an interview on 8/15/17 at 2:00 p.m., the staff with the fire profession service said he did not have a specific date when the internal investigation had been done. It had been in the last 4 to 5 years.

Based on observation, the facility failed to ensure doors were provided with means suitable for keeping the door closed in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.5. This deficiency affects 1 of 2 smoke compartments.

Findings include:

1. During an observation on 8/16/17 at 8:20 a.m., when the corridor door to the soiled utility room was exercised it did not close completely and latch.

2. During an observation on 8/16/17 at 9:07 a.m., the door into the pharmacy in the clinic did not latch when exercised.

Based on observation, the facility failed to ensure that a grill was not stored under an overhanging portion of the building in accordance with NFPA 1, Fire Code, 2012 Edition, Section 10.11.6.1. This deficiency affects 1 of 2 smoke compartments.

Findings include:

1. During observations on 8/14 and 15/17 a gas grill was stored on the patio up against the building in a courtyard underneath an overhang of the building.

Based on observation and interview, the facility failed to ensure where a fusible link was installed the fusible link was removed for testing the damper for full closure, simulating a fire condition in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives, 2010 Edition, Sections 6.5.5. This deficiency affects 2 of 2 smoke compartments.

Findings include:

1. In an interview on 8/16/17 at 9:35 a.m., staff member A said when he looked there was no fusible link. There is an actuator and it was tested.

During an observation on 8/16/17 at 9:35 a.m., the damper in the smoke barrier was examined. There was a fusible link in the damper.