HospitalInspections.org

Based on observation, and staff interviews it was determined the facility failed to Assure fire protection systems worked properly

This could place all Staff & Residents at risk in the event of Fire

The findings include:
During a tour of the facility with Staff M on
08/28/2018 between 10:00 am and 5:00 pm observation revealed that Fire Alarm Strobes were found to be out of Syncronization in buildings A & B.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, 19.3.4.3, 9.6.3.4, 2010 NFPA 72, 18.5.4.3.2, A 18.5.4.3.2

Based on observation, and staff interviews it was determined the facility failed to Assure constant readiness of Fire Alarm System.

This could place all Staff & Residents at risk in the event of Fire.

The findings include:
During a tour of the facility with Staff M on
08/28/2018 between 10:00 am and 5:00 pm observation revealed that a "Trouble" Indicator was identified on the Fire Alarm Control Panel.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101 Chapter 19, Section19.3.4.4, to Chapter 9, 9.6.5.1, to 2010 NFPA 72, Chapter 14, Section 14.2.1.2.2

Based on observation, and staff interviews it was determined the facility failed to Maintain all Sprinkler systems to optimum Readiness.

This could place all Staff & Residents at risk in the event of Fire.

The findings include:
During a tour of the facility with Staff M on
08/28/2018 between 10:00 am and 5:00 pm observation revealed that 1) Sprinkler Riser in Admin Building was found Yellow Tagged. 2) Sprinkler escutcheons and covers were missing in Kitchen and in C-2 Building laundry. 3) No sprinkler Data Design Plate on the Administration building Sprinkler riser. 4) Sprinkler in Bldg-B needs height adjustment in Hallway at Laundry.

These findings were confirmed by Staff M at the time of discovery.

Reference: 1) 2012 NFPA 101 Chapter 19, Section 19.3.5.1, Chapter 9, Sections 9.7.1.1, 9.7.5, 9.7.7, 9.7.8, Chapter 4, Section 4.6.12.1 and 2011 NFPA 25 Chapter 4, Section 4.1.4.1
2) 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
3) 2012 NFPA 101, Chapter 19, Sections 19.3.5.1, 19.1.1.1.3, Chapter 9, Section 9.7.5, Chapter 4, Section 4.6.12.1 and 2011 NFPA 25, Chapter 5, Section 5.2.6
4) 2012 NFPA 101, Chapter 19, Sections 19.3.5.1, 19.1.1.1.3, Chapter 9, Section 9.7.5, Chapter 4, Section 4.6.12.1 and 2011 NFPA 25, Chapter 5, Sections, 5.2.3.1, 5.2.3.2

Based on observation, and staff interviews it was determined the facility failed to keep Multi-outlet strips and battery Back up power supply unit off of the floor.

This could place All Staff & Residents at risk in the event of Fire

The findings include:
During a tour of the facility with Staff M on
08/28/2018 between 10:00 am and 5:00 pm observation revealed that 1) multi-outlet power strips (AKA: MOPS) were found throughout facilities on the floor. 2) missing circuit board addresses of multiple circuits.

These findings were confirmed by Staff M at the time of discovery.

Reference: 1) 2012 NFPA 101, Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1.2, then 2011 NFPA 70 Article 380.12 (2)

2) 2012 NFPA 101 Chapter 19, Section 19.5.1.1, Chapter 9, Section 9.1.2, then to 2011 NFPA 70 Article 408.4 (A)

Based on observation, and staff interviews it was determined the facility failed to assure only approved heat sources in the Facility

This could place 32 Staff & Residents at risk in the event of Fire

The findings include:
During a tour of the facility with Staff M on
08/28/2018 between 10:00 am and 5:00 pm observation revealed that a portable space heater was found in the admissions office. No Documentation was available stating the heating element did not exceed 212 degrees fahrenheit.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101 Chapter 19, Section 19.7.8