HospitalInspections.org

Reference: NFPA 10, 2012 Edition1
9.2.10 Marking of Means of Egress.

19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.

19.2.10.2 Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons.

19.2.10.3 Where the path of egress travel is obvious, signs shall not be required at gates in outside secured areas.

19.2.10.4 Access to exits within rooms or sleeping suites shall not be required to be marked where staff is responsible for relocating or evacuating occupants.

7.10.2 Directional Signs.

7.10.2.1* A sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

7.10.6.2* Size and Location of Directional Indicator.

7.10.6.2.1 Directional indicators, unless otherwise provided in 7.10.6.2.2, shall comply with all of the following:
(1) The directional indicator shall be located outside of the EXIT legend, not less than 3.8 in. (9.5 mm) from any letter.
(2) The directional indicator shall be of a chevron type, as shown in Figure 7.10.6.2.1.
(3) The directional indicator shall be identifiable as a directional indicator at a distance of 40 ft (12 m).
(4) A directional indicator larger than the minimum established for compliance with 7.10.6.2.1(3) shall be proportionately increased in height, width, and stroke.
(5) The directional indicator shall be located at the end of the sign for direction indicated.


Based on observation and interview, facility failed to ensure illuminated exit signs in need of directional indicators (chevron's/arrows) were installed on exit signs. This deficient practice could present a potential risk of harm by confusion and delay of evacuation in the event of and emergency or fire to all eight patients occupying the facility, as identified by the admitted patient list provided by the CEO (Chief Executive Officer) on 08/29/23.

The findings are.

A. On 08/30/23 at 10:20 am, during observation of illuminated exit sign located at entrance to Imagine, the sign did not have a directional arrow to indicate egress path to the exit route of the nearest exit.

B. On 08/30/23 at 10:30 am, during interview, Director of Plant Operations stated he was aware of the problem and was in the process of addressing other exit signs out of compliance.

Reference: NFPA 101, (2012 Edition)

19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.


Reference: NFPA 17A, (2009 Edition)

7.2 Owner's Inspection.
7.2.1 On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual.
7.2.2 At a minimum, this "quick check" or inspection shall include verification of the following:
(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
(3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that might prevent operation.
(6) The pressure gauge(s), if provided, shall be inspected physically or electronically to ensure it is in the operable range.
(7) The nozzle blowoff caps, where provided, are intact and undamaged.
(8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated.

7.2.3 If any deficiencies are found, appropriate corrective action shall be taken immediately.

7.2.3.1 Where the corrective action involves maintenance, it shall be conducted by a service technician as outlined in 7.3.1.

7.2.4 Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.

7.2.5 At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded.

7.2.6 The records shall be retained for the period between the semiannual maintenance inspections.



Based on observation and interview, the facility failed to ensure the fire-extinguishing system, which protects the range hood within the kitchen, was inspected at least monthly (Owner's Inspection), as required by NFPA 17A (Standard for Wet Chemical Extinguishing Systems). Not maintaining this system is likely to result in less than optimal system performance in the event of fire, which potentially present a risk of harm to all eight patients occupying the facility, as identified by admitted patient list provided by the CEO (Chief Executive Officer), on 08/29/23.

The findings are:

A. On 08/30/23 at 8:45 am, based on observation in the kitchen, the range hood fire-extinguishing system did not have an owners inspection conducted on a monthly basis. Last service date was conducted on March 22, 2023

B. On 08/30/23 at 8:50 am, during interview, the Director of Plant Operations stated the monthly inspection will be conducted as required for the visual verification of the systems readiness.


Reference;
NFPA 101 Life Safety Code (2012 Edition)

19.3.2.5 Cooking Facilities.

19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless other wise permitted by 19.3.2.5.2, 19.3.2.5.3 or 19.3.2.5.2.

9.2.3 Commercial Cooking Equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (2011 Edition)

11.7 Cooking Equipment Maintenance.
11.7.1 Inspection and servicing of the cooking equipment shall be made at least annually by properly trained and qualified persons.

Based on interview and record review of commercial cooking equipment (appliances), the facility failed to ensure that annual servicing of commercial cooking equipment had been conducted within the last 12 months. Not having commercial cooking equipment serviced/inspected annually could result in a fire from possible failure of the equipment. This deficient practice presents a risk of potential harm by fire to all eight patients occupying the facility, as identified by the admitted patient list provided by the CEO (Chief Executive Officer) on 08/29/23.

The findings are:

A. Record review of commercial cooking equipment indicated the record did not contain evidence of annual servicing of appliances conducted within the last twelve months.

B. On 08/29/23 at 2:10 pm, during interview, Director of Plant Operations stated, "I have not located any documentation to indicate the appliances were inspected within the last twelve (12) months as required."

Reference:

NFPA 101, 2012 Edition

19.3.4 Detection, Alarm, and Communications Systems.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

19.3.4.2* Initiation.
19.3.4.2.1 Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices,
or detection systems, unless otherwise permitted by 19.3.4.2.2 through 19.3.4.2.4.

9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1* General.
9.6.1.1 The provisions of Section 9.6 shall apply only where specifically required by another section of this Code.
9.6.1.2 Fire detection, alarm, and communications systems installed to make use of an alternative permitted by this Code shall be considered required systems and shall meet the provisions of this Code applicable to required systems.

9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and
NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

Based on observation and interview, facility failed to ensure a smoke detection device was installed in the gift shop. Not having detection devices installed in all rooms containing large amounts of combustibles could result in an undetected fire. This deficient practice presents a risk of potential harm by fire to all eight patients occupying the facility as identified by the admitted patient list provided by the CEO (Chief Executive Officer) on 08/29/23.

The findings are:

A. On 08/30/23 at 10:35 am, during observation of the Gift Shop (located in main lobby), revealed the shop did not contain a smoke detection device, and the shop was open to the corridor.

B. On 08/30/23 at 10:40 am during interview, Director of Plant Operations indicated a device should be installed.

NFPA 101, 2012 Edition Chapter 19 Existing Health Care Occupancies

19.3.5 Extinguishment Requirements.
19.3.5.1 Buildings containing nursing homes 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.

19.3.5.2 High-rise buildings shall comply with 19.4.2.

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.

19.3.5.4* The sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7.1.1(1).

9.7.1 Automatic Sprinklers.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13 D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13 R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height.

NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 Edition

Installation Requirements
8.1* Basic Requirements.

8.1.1* The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers shall be installed throughout the premises.
(2) Sprinklers shall be located so as not to exceed the maximum protection area per sprinkler.
(3) Sprinklers shall be positioned and located so as to provide satisfactory performance with respect to activation time and distribution.
(4) Sprinklers shall be permitted to be omitted from areas specifically allowed by this standard.
(5) When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
(6) Clearance between sprinklers and ceilings exceeding the maximums specified in this standard shall be permitted, provided that tests or calculations demonstrate comparable
sensitivity and performance of the sprinklers to those installed in conformance with these sections.
(7) Furniture, such as portable wardrobe units, cabinets, trophy cases, and similar features not intended for occupancy, does not require sprinklers to be installed in them. This type of feature shall be permitted to be attached to the finished structure.

Based on observation and interview, facility failed to ensure sprinkler system was installed in all areas required. Not having proper sprinkler protection coverage in areas required could result in a uncontrollable fire. This deficient practice presents a risk of injury by fire to all eight patients occupying the facility, as identified by the admitted patient list provided by the CEO (Chief Executive Officer) on 08/29/23.

The findings are.

A. On 08/30/23 at 9:40 am, observation of the two kitchen walk-in freezers, both units did not contain sprinkler protection.

B. On 08/30/23 at 9:50 am, during interview, the Plant Operations Director stated no one has brought this to their attention, and he did not notice there was not sprinkler protection in the walk-in coolers.

NFPA 101, Life Safety Code, 2012 Edition

19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
19.5.1.2 Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.

9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations,
which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition

406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a recess-mounted receptacle shall effectively close the opening and seat against the mounting surface.



Based on observation and interview, the facility failed to ensure electrical wiring was properly installed with all exposed wiring concealed or covered with proper protective shields. Not having all electrical wiring protected, concealed or covered, could result in arching an (arc-fault occurs when loose or corroded connections make intermittent contact and causes sparking or arcing between connections or damaged wiring), which could cause a fire or electrocute any one who would come in contact with the exposed wiring. This deficient practice presents a potential risk of injury to all eight patients occupying the facility, as identified by the admitted patient list provided by the CEO (Chief Executive Officer) on 08/29/23.

The findings are:

A. On 08/30/23 at 10:10 am, during observation of the IT (Information Technology) room
#134, revealed an open electrical junction box did not have a protective cover plate. The junction box contained exposed electrical wiring.

B. On 08/30/23 at 10:25 am, during interview, the Director of Plant Operations stated he had not noticed the cover plate missing.

NFPA 101, 2012 Edition

19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

19.7.1.8 Employees of health care occupancies shall be in instructed in life safety procedures and devices.


Based on record review and interview, the facility failed to ensure fire drills were conducted at unexpected/varied times and conditions (i.e. snow storm, hail storm, heavy winds, etc.), on all nursing shifts, and not to exceed 90 days, to ensure preparedness for emergencies. This deficient practice could likely result in staff not being adequately prepared to exercise their duties in accordance to the facility's fire preparedness plan in the event of fire. This failed practice presents a risk of potential harm to all eight patients occupying the facility as identified by the patient admitted list provided by the CEO (Chief Executive Officer) on 08/29/23.

The findings are:

A. Record review of the fire drill log indicated the facility has three nursing shifts:
1. First shift (7:30 AM - 3:30 PM);
2. Second shift (3:30 PM - 11:30 PM);
3. Third shift (11:30 PM - 7:30 AM).

B. Record review of the fire drill documentation indicated the staff did not conduct fire drills on the second and third shifts, between September 2022 thru December on 2022.

C. On 08/29/23 at 1:25 pm, during an interview, the Director of Plant Operations stated he could not locate any documentation to indicate the drills were done.