HospitalInspections.org

Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 0 of 26 residents.

Findings:

During the facility tour on 4/25/2017, 4/26/2017 and 4/27/2017, between the hours of 8:30am to 2:30pm it was observed that hospital office rooms 1, 2, 15, 16 and 17 are lacking pendant or sidewall sprinkler coverage.

Interview with Safety Program Coordinator revealed the facility was not aware the automatic sprinkler system was not complete

Based on visual observation the facility failed to assure the construction of the smoke barrier cross corridor fire glazed/ resistance windows. The smoke barriers are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 0 of 0 residents, 1 of 4 cross corridor smoke barriers were deficient.

Findings:

During the facility tour on 4/25/17, 4/26/2017 and 4/27/2017 it was observed between the hours of 8:30am to 2:30pm the cross corridor smoke doors ward 3 nearest elevator / mechanical room is lacking a fire glazed vision window.

Interview with Safety Program Coordinator revealed the facility was not aware of unsealed penetration.

Based on visual observation the facility is lacking a generator remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard wired to indicate alarm conditions of the emergency power source. A centralized compute system (e. g., building information system) is not to be substituted for the alarm annunciator. NFPA 110:5.6.5.2 (4) an individual alarm indicator to annunciate any of the conditions listed in Table 5.6.5.2.The deficiency has the potential to affect 100 of 100 residents.

During the facility tour on 4/25/2017, 4/26/2017 and 4/27/2017, between the hours of 8:30am to 2:30pm it was observed the generator used to provide a Type 3 EES life safety branch lacks a remotely located annunciator.

Interview with Safety Program Coordinator revealed the facility is in the processes of installing a generator remotely located annunciator.

Based on visual observation the facility is lacking a generator remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard wired to indicate alarm conditions of the emergency power source. A centralized compute system (e. g., building information system) is not to be substituted for the alarm annunciator. NFPA 110:5.6.5.2 (4) an individual alarm indicator to annunciate any of the conditions listed in Table 5.6.5.2.The deficiency has the potential to affect 40 of 40 residents.

During the facility tour on 4/25/2017, 4/26/2017 and 4/27/2017, between the hours of 8:30am to 2:30pm it was observed the generator used to provide a Type 3 EES life safety branch lacks a remotely located annunciator.

Interview with Safety Program Coordinator revealed the facility is in the processes of installing a generator remotely located annunciator.

Based on visual observation the facility is lacking a generator remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard wired to indicate alarm conditions of the emergency power source. A centralized compute system (e. g., building information system) is not to be substituted for the alarm annunciator. NFPA 110:5.6.5.2 (4) an individual alarm indicator to annunciate any of the conditions listed in Table 5.6.5.2.The deficiency has the potential to affect 92 of 92 residents.

During the facility tour on 4/25/2017, 4/26/2017 and 4/27/2017, between the hours of 8:30am to 2:30pm it was observed the generator used to provide a Type 3 EES life safety branch lacks a remotely located annunciator.

Interview with Safety Program Coordinator revealed the facility is in the processes of installing a generator remotely located annunciator.