HospitalInspections.org

A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test must be conducted for 1 ½-hour duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction.

Review of records indicated the facility failed to conduct monthly thirty (30) second and annual 1 ½-hour tests on the emergency battery pack lights throughout the facility.

Failure to provide emergency lighting as required increases the risk of death or injury due to fire.

The deficiency affected all emergency battery back-up lights throughout the building.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

Observation determined four (4) skylights, 5 feet by 6 feet and approximately 8 feet deep in the Dialysis Unit lacked sprinkler coverage.

Failure to provide complete coverage of the automatic sprinkler system increases the risk of death or injury due to fire.

The deficiency affected one (1) of six (6) smoke compartments in the building.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Record review determined the facility failed to conduct a quarterly test of the sprinkler system during the first quarter of 2015.

Failure to test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) required quarterly tests of the automatic sprinkler system since the facility was occupied in December 2014.

Fireplaces shall be permitted and used only in areas other than patient sleeping areas, provided that such areas are seperated from patient sleeping areas by construction having not less than a 1-hour fire resistance rating and that such fireplaces comply with the provisions of 9.2.2. 18.5.2.2 Exception No. 2.

The facility failed to separate areas containing gas fireplaces from patient sleeping areas with one-hour fire resistive rated partitions.

Observation determined the Nursery was located in the same smoke compartment as the gas fireplace in the Main Lobby.

Failure to separate patient sleeping rooms from fuel-fired devices by construction having not less than one-hour fire resistance rating increases the risk of death or injury due to fire.

This deficiency affected one (1) of six (6) smoke compartments in the building.

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

1) The facility failed to inspect the emergency generator on a weekly basis.

Review of records did not indicate a weekly visual inspection of the emergency generator was completed.

2) Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

Review of documentation did not indicate the specific gravity of the batteries for the emergency generator were tested.

Failure to inspect and maintain the emergency generator in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) emergency generator.

A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test must be conducted for 1 ½-hour duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction.

Review of records indicated the facility failed to conduct monthly thirty (30) second and annual 1 ½-hour tests on the emergency battery pack lights throughout the facility.

Failure to provide emergency lighting as required increases the risk of death or injury due to fire.

The deficiency affected all emergency battery back-up lights throughout the building.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

Observation determined four (4) skylights, 5 feet by 6 feet and approximately 8 feet deep in the Dialysis Unit lacked sprinkler coverage.

Failure to provide complete coverage of the automatic sprinkler system increases the risk of death or injury due to fire.

The deficiency affected one (1) of six (6) smoke compartments in the building.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Record review determined the facility failed to conduct a quarterly test of the sprinkler system during the first quarter of 2015.

Failure to test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) required quarterly tests of the automatic sprinkler system since the facility was occupied in December 2014.

Fireplaces shall be permitted and used only in areas other than patient sleeping areas, provided that such areas are seperated from patient sleeping areas by construction having not less than a 1-hour fire resistance rating and that such fireplaces comply with the provisions of 9.2.2. 18.5.2.2 Exception No. 2.

The facility failed to separate areas containing gas fireplaces from patient sleeping areas with one-hour fire resistive rated partitions.

Observation determined the Nursery was located in the same smoke compartment as the gas fireplace in the Main Lobby.

Failure to separate patient sleeping rooms from fuel-fired devices by construction having not less than one-hour fire resistance rating increases the risk of death or injury due to fire.

This deficiency affected one (1) of six (6) smoke compartments in the building.

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

1) The facility failed to inspect the emergency generator on a weekly basis.

Review of records did not indicate a weekly visual inspection of the emergency generator was completed.

2) Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

Review of documentation did not indicate the specific gravity of the batteries for the emergency generator were tested.

Failure to inspect and maintain the emergency generator in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) emergency generator.