HospitalInspections.org

K 324
The facility did not ensure that the design, installation and use of its commercial cooking equipment were in accordance with NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations as required by the referenced LSC.

On 08/12/19 at 11:40 AM, the surveyor, while accompanied by the Director of Facilities, observed that the wheeled, natural gas-fired cooking appliances located on the cooking line in the kitchen were provided with a restraint system to prevent damage to the flexible, fuel lines-as required by NFPA 96 & 54; however on the day of survey they were not attached as required.

K 0345
The facility did not ensure that a fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70, 72 and NFPA 101 section 9.6.1

On 08/12/19 at 10:15 AM, the surveyor was not provided with documentation by the Director of Facilities to indicate that all devices related the fire alarm system were functionally tested annually / visually inspected semi-annually including battery testing and inspection as required by NFPA 70, 72 and NFPA 101 section 9.6.1; i.e., last inspection was 05/03/19,and the previous inspection was completed on 09/04/18 exceeding the semi-annual requirement for inspection and testing by 3 months and deficiencies identified on both inspections were not corrected until the day of survey. The heat detectors in the boiler house also were not inspected due to height in violation of the National Fire Alarm Code NFPA 72 requirements of annual testing.

K 0353
The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC and NFPA 25"Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems".

On 08/12/19 at 10:20 AM, the surveyor was not provided with documentation by the Director of Facilities to indicate that the sprinkler heads in service for fifty (50) years (sprinkler heads were dated 1967 a period of 52 years) in the bissel wing and, had not been replaced or a representative samples from one or more sample areas were submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field testing as required by NFPA 25 "Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems".

K 372
The facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.5 as required by the referenced LSC 19.3.7.3,

On 08/08/19 at 10:30 AM and at other times throughout the survey, the surveyor while accompanied by representative of the Director of Facilities observed that there were voids around penetrations and within conduit used for the passage of wires through the smoke barrier walls throughout the facility that were not sealed using a UL approved system for fire stopping through a smoke barrier / fire barrier