HospitalInspections.org

Based on observation and facility staff interview, facility staff failed to ensure areas open to the corridor contained smoke detection per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The facility census was

Observations on 1/25/23, during the facility tour, showed the following area open to the designated exit corridors requiring smoke detectors:

- Med Surge Sub Kitchen

During an interview on 1/25/23 at 12:36 P.M., the Maintenance Manager confirmed the observation.

19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on record review and facility staff interview, facility staff failed to inspect one of one wet sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was

1) Record review on 1/25/23 did not show the following inspections:

- quarterly inspections/testing (Table 13.1.1.2)

- monthly inspections

During an interview on 1/25/23 at 2:25 P.M.,, the Maintenance Manager said he did not know the sprinkler system inspection requirements.

Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13, and 14 for additional information.

13.4.2 Check Valves.
13.4.2.1 Inspection. Valves shall be inspected internally every
5 years to verify that all components operate correctly, move
freely, and are in good condition.

Based on observation and interview the facility staff failed to maintain one of one designated smoking areas in a manner free from fire hazards and ensure the proper disposal of cigarette waste in metal self-closing cigarette disposal containers. This deficient practice has the potential to affect facility occupants who use the smoking area. The facility census was .

1. Observation on 1/25/23 during the facility tour, showed the designated smoking area did not contain a metal self-closing cigarette disposal container or ashtrays of safe design. Observation showed cigarette butts in a container attached to a trash can.

During an interview on 1/25/23 at 1:51 P.M., the Maintenance Manager confirmed the observation.

Review of the NFPA 101, 2012 Edition, showed:
-19.7.4 "Smoking regulations shall be adopted and shall include not less than the following provisions:
(5)Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted."
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted."

Based on observation and facility staff interview, facility staff failed to provide an emergency stop switch outside the generator enclosure for one of one emergency generators. The facility census was .

1) Observation on 1/23/23, during the facility tour, showed the emergency generator emergency stop switch located within the generator enclosure.

During an interview on 1/25/23 at 10:54 A.M., the Maintenance Manager said there is not another emergency stop switch besides the one installed on the generator enclosure.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition states:

5.6.5.6* All installations shall have a remote manual stop station
of a type to prevent inadvertent or unintentional operation located
outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is
located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled.