HospitalInspections.org

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 3 of 3 residents.

Findings:

During the facility tour, between the hours of 10:30 am to 3:30 pm on 9/15/2017 it was observed the fire alarm sensitivity test was last conducted in the year 2010.

Interview with Maintenance Supervisor revealed the facility was not aware that the required inspections had not been conducted on the fire alarm system.

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 3 of 3 residents.

Findings:

During the facility tour, between the hours of 10:30 am to 3:30 pm on 9/15/2017 it was observed the riser room sprinkler is not properly installed and is lacking interior sheetrock wall above the height of the door frame for the surrounding walls in the room.

Interview with the Maintenance Supervisor revealed the facility was not aware the automatic sprinkler system was not complete.

Based on visual observation the facility failed to assure that the automatic sprinkler system has supervised valves that will sound a local alarm if closed. A direct result, of the fire alarm system being notified of the emergency, is protection of life and property. This deficiency has the potential to affect 3 of 3 residents.

Findings:

During the facility tour, between the hours of 10:30 am to 3:30 pm on 9/15/2017 it was observed sprinkler system control valve tamper switch is not calibrated properly nor is it sending a supervisory trouble signal to the fire alarm panel when the tamper switch is actuated.

Interview with Maintenance Supervisor revealed the facility was not aware that the valves on the sprinkler system were not supervised by the fire alarm system.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls 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 3 of 3 residents.
1 of 1 smoke barriers were deficient.

Findings:

During the facility tour, between the hours of 10:30 am to 3:30 pm on 9/15/2017 it was observed the southern and western wings have a shared smoke barrier with approximately a 10 inch X 10 inch penetration that is not properly sealed and foam firestopping material has improperly been installed in all the locations intumescent fire stopping material should be used in the ½ hour smoke barrier.

Interview with Maintenance Supervisor revealed the facility was not aware of the unsealed penetrations.