HospitalInspections.org

Based upon observations made in the presence of the plant manager on July 20, 2016, it was determined that the
facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance
with NFPA 101 19.3.2.1.

This deficiency affected 1 of 6 smoke compartments.

Findings include:

During the tour of the facility, made with the facility director, it was observed that both the communications room and the phone room contained several wall penetrations 1-2 " in size and several unsealed conduits reducing the fire rating of the room in accordance with NFPA 101 19.3.2.1.

Based upon observations made in the presence of the plant manager on July 20 ,2016, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 101 19.3.4.4; 9.6.1.4.; and NFPA 72.

This deficiency affected 1 of 6 smoke compartments.

Findings include:

During the tour of the facility, made with the facility director, it was observed that the fire pull station was blocked in the dietary food prep area by a cart of supplies. In accordance with NFPA 72 2-8.2.1 manual operated pull stations for the fire alarm need to remain unobstructed.

Based upon observations made in the presence of the plant manager on July 20, 2016, it was determined that the facility did not maintain, inspect and exercise the facilities emergency generator set in accordance with NFPA 99.

This deficiency affects 1 of several generator tests required

Findings include:

During document review and staff interview with the facility director the facility failed to provide documentation that the annual load bank test was conducted on the emergency generator with in the last 12 months in accordance with NFPA 99 3-4.4.1.1; NFPA 110 6-4.2.2.

Based upon observations made in the presence of the plant manager on July 20,2016, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1; 9.1.2.

This deficiency affected 2 of 6 smoke compartments.

Findings include:

During the building tour it was observed that the hospital was using two power strips daisy chained together to supply power to a piece of equipment. In accordance with the manufactures UL listing, power strips are not to be plugged into one another.

During the building tour it was observed that the hospital had equipment stored in front of the electrical panel in the laundry room. In accordance with NFPA 10119.5.1; 9.1.2; NFPA 70 110-26 electrical panels are to have 36 " of clear space in front of them at all times.

During the building tour it was discovered that the hospital was leaving the door to the electrical room in the acute care corridor and the electrical panels unlocked making them available to unauthorized personnel. In accordance with NFPA 70,110-31 (c ) electric panels are to be kept locked to unauthorized personnel.

Based upon observations made in the presence of the plant manager on July 20, 2016, it was determined that the
facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance
with NFPA 101 19.3.2.1.

This deficiency affected 1 of 6 smoke compartments.

Findings include:

During the tour of the facility, made with the facility director, it was observed that both the communications room and the phone room contained several wall penetrations 1-2 " in size and several unsealed conduits reducing the fire rating of the room in accordance with NFPA 101 19.3.2.1.

Based upon observations made in the presence of the plant manager on July 20 ,2016, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 101 19.3.4.4; 9.6.1.4.; and NFPA 72.

This deficiency affected 1 of 6 smoke compartments.

Findings include:

During the tour of the facility, made with the facility director, it was observed that the fire pull station was blocked in the dietary food prep area by a cart of supplies. In accordance with NFPA 72 2-8.2.1 manual operated pull stations for the fire alarm need to remain unobstructed.

Based upon observations made in the presence of the plant manager on July 20, 2016, it was determined that the facility did not maintain, inspect and exercise the facilities emergency generator set in accordance with NFPA 99.

This deficiency affects 1 of several generator tests required

Findings include:

During document review and staff interview with the facility director the facility failed to provide documentation that the annual load bank test was conducted on the emergency generator with in the last 12 months in accordance with NFPA 99 3-4.4.1.1; NFPA 110 6-4.2.2.

Based upon observations made in the presence of the plant manager on July 20,2016, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1; 9.1.2.

This deficiency affected 2 of 6 smoke compartments.

Findings include:

During the building tour it was observed that the hospital was using two power strips daisy chained together to supply power to a piece of equipment. In accordance with the manufactures UL listing, power strips are not to be plugged into one another.

During the building tour it was observed that the hospital had equipment stored in front of the electrical panel in the laundry room. In accordance with NFPA 10119.5.1; 9.1.2; NFPA 70 110-26 electrical panels are to have 36 " of clear space in front of them at all times.

During the building tour it was discovered that the hospital was leaving the door to the electrical room in the acute care corridor and the electrical panels unlocked making them available to unauthorized personnel. In accordance with NFPA 70,110-31 (c ) electric panels are to be kept locked to unauthorized personnel.