HospitalInspections.org

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Based on observation and interview, the facility failed to maintain the means of egress per the requirements of:

2012 NFPA 101, 39.2.1, and 7.2.2.4.1.1

This deficiency could affect 10 occupants.

Findings include:

On 04/11/2019, during a tour of the facility from 08:00 am to 12:30 pm, the surveyor observed a ramp with a broken outside handrail in the means of egress by Room 420 exit. The right handrail could not be of use to occupants because it was leaning approximately 45 degrees outwards from the ramp.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and interview, the facility failed to ensure the visual function of the notification devices for the fire alarm was per the requirements of:

2012 NFPA 101, 18.3.4.3.1, and 9.6.3.5
2010 NFPA 72, 10.10.2

Findings include:

On 04/10/2018, during a tour of the facility from 6:00 pm to 10:00 pm, the surveyor observed fire alarm visual notification devices continued to function after the signal deactivation means was actuated.

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation and interview, the facility failed to maintain the smoke detectors per the requirements of:

2012 NFPA 101, 4.6.12.3, 4.6.12.4, and 9.6.1.3
2010 NFPA 72, 14.4.5.3.2

This deficiency could affect all occupants.

Findings include:

On 04/11/2019, during a tour of the facility from 8:00 am to 12:30 pm, the facility failed to provide documentation that a smoke detector sensitivity test was completed within the past two years.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to ensure the automatic sprinkler system was per the requirements of:

2012 NFPA 101, 18.3.5.1, 18.3.5.4, and 9.7.1.1 (1)
2010 NFPA 13, 8.5.6.1

Findings include:

On 04/09/2019, during a tour of the facility from 1:00 pm to 4:15 pm, the surveyor observed boxes of kitchen food and supplies were stored within 18 inches of the automatic sprinkler heads in the following locations:
1. The kitchen walk in cooler
2. The kitchen walk in freezer
3. The Dry Storage Room

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain the automatic sprinkler system per the requirements of:

2012 NFPA 101, 18.3.5.1, and 9.7.5
2011 NFPA 25, 5.2.4.1, and 5.2.2.2

Findings include:

1. On 04/09/2019, during a tour of the facility from 1:00 pm to 4:15 pm, the facility failed to provide documentation for the monthly inspections on the wet sprinkler system gauges.

2. On 04/10/2019, during a tour of the facility from 8:00 am to 2:00 pm, the surveyor observed an HVAC supply air duct resting on the automatic sprinkler system pipes above ceiling near the Education Work Room and Room 1C191.

A member of the maintenance staff was present when this deficiency was identified.
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39327

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Based on review of documentation and interview, the facility failed to provide documentation on the testing and inspection of the automatic sprinkler system per requirements of:

2012 NFPA 101, 4.6.12.3, 4.6.12.4, 9.7.5, and 9.7.7
2011 NFPA 25, Table 5.1.1.2, 5.2.4.1, 5.3.4, and TIAs 11-1, 11-2, 11-3 and 11-4

This deficiency could affect all occupants.

On 04/11/2019, during a tour of the facility from 8:00 am to 12:30 pm, the facility failed to provide the following documentation :

1. The monthly inspections on the wet sprinkler riser gauges
2. The quarterly automatic sprinkler inspection records for the past 12 months. Only one report dated 02/20/2019 was provided for review. The service tags on the riser indicated 08/2018, 08/17, 09/16, 02/16 as dates the system was inspected.

A member of the maintenance staff was present when the deficiency was found.
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Based on observation and interview, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 18.3.7.3, 8.5.1, and 8.5.6.2

Findings include:

On 04/09/2019, during a tour of the facility from 1:00 pm to 4:15 pm, the surveyor observed the following in smoke barriers above the ceiling on the Third Floor:

1. An unsealed penetration of approximately 2 inches at the entrance to the Baby Wing
2. An unsealed penetration around the HVAC duct on Wing 3100 above the doors

A member of the maintenance staff was present when this deficiency was identified.