HospitalInspections.org

Based on observation it was determined that the facility failed to keep the sprinkler heads clean. Failing to maintain the sprinkler heads which are part of the entire sprinkler assembly could cause harm to the residents by allowing a fire to spread before the temperature is reached to set off the sprinkler head.

NFPA 101 Life Safety Code, 2012 edition, Chapter 19, Section 19.3.5.3
Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. Chapter 9, Section 9.7.1 "Each automatic sprinkler system required by another section of this Code shall be in accordance with on of the following." " NFPA 13, Standard for the Installation of Sprinkler Systems." Chapter 26, Section 26.1 "General." "A sprinkler system installed in accordance with standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25. NFPA 25, Section 5.2.1 "Sprinklers, Section 5.2.1.1.1 "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage." Section 5.2.1.1.2 Any sprinkler that shows the signs of any of the following shall be replaced. 1. leakage
2. Corrosion 3. Physical damage 4. Loss of fluid in the glass bulb heat responsive element
5. * Loading See A.5.2.1.1.2 (5) In lieu of replacing sprinklers that are loaded with a coating of dust , it is permitted to clean sprinklers with compressed air or by a vacuum provided that the equipment does not touch the sprinkler. 6. Painting unless painted by the manufacturer. Section 5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage, is painted other than by the manufacturer, corroded, damaged, or loaded, is in the improper orientation. Annex E Examples of Classification of needed repairs Sprinklers and Escutcheon plates that are missing, painted or rusted.

Findings Include:

Observations while on tour November 17, 2020 revealed that eight (8) out of eleven (11) heads were dirty in the kitchen area.

During the exit conference employee #40 confirmed that eight (8) out of eleven (11) heads were dirty in the kitchen area.

Based on observation it was determined the facility failed to Maintain the ceiling tiles throughout the facility. Failing to seal the penetrations, holes and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients inthe event of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

Observations while on tour November 17,2020 reveled damaged ceiling tiles in over half the rooms of the facility. In addition some of the tiles showed water damage leaving gaps in the smoke barrier that protects the segregated areas of the hospital.

Employees #1, #40 and #49 aknowleged during the exit conference conducted on November 18,2020 the damaged ceiling tiles in over half the rooms of the facility and the water damaged tiles leaving gaps in the smoke barrier that protects the segregated areas of the hospital.

Based on Record Review and Interview the facility failed to properly document weekly generator testing of the generator batteries. Failure to inspect weekly, and document results could result in harm to patients during emergency system failures.

NFPA 101 Life Safety Code, 2012, Chapter19, Section 19.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 8.4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 8, Section 8.4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...

Findings Include:

Observations while on tour and review of documents November 17, 2020 revealed the facility failed to perform or document the continuity or conductivity tests on the emergency diesel generator.

Employees #1, #40 and #49 acknowledged during the exit conference on November 18, 2020 that the facility failed to document the continuity or conductivity tests on the emergency diesel generator.