HospitalInspections.org

Based on observation, the provider failed to meet the minimum construction standards of the 2012 Life Safety Code (LSC) due to the removal of the gypsum ceiling. Findings include:

1. Observation on 7/12/22 at 10:30 a.m. revealed the building was four stories and did not have a ceiling in the air compressor/mechanical room which exposed the steel bar joist structural system. The fire protection rating for the structure was lowered to an unprotected level due to that condition.

The building meets the FSES. Please mark an "F" in the completion date column to indicate the correction of the deficiencies identified in K000.

Based on record review and interview, the provider failed to maintain one of one fire alarm system as required. Findings include:

1. Record review on 7/11/22 at 4:30 p.m. revealed the annual fire alarm inspection report dated 5/25/22 did not list sensitivities for the ionization-type smoke detectors.

Ref: 2010 NFPA 72 Section 14.6.2.4, Figure 14.6.2.4 Section 7.12-7.14 and page 11 of 11

2. Interview with the operations manager at the time of the record review confirmed those findings. He stated the contractor who provided the testing only confirmed a pass or fail condition.

The deficiency affected 100% of the occupants.

Based on record review and interview, the provider failed to document generator battery conductivity monthly (no documentation for 2020 and 2021). Findings include:

1. Record review on 7/11/22 at 4:00 p.m. revealed there was not any documentation of the battery conductivity in the monthly maintenance logs for the generator for calendar year 2020 and 2021. Interview with the maintenance supervisor at 4:00 p.m. on 7/11/22 revealed the generator had a maintenance-free battery installed and it could not be tested for specific gravity. He stated he was unaware of the monthly battery conductivity documentation requirement that replaced the specific gravity testing for the battery.

The deficiency affected 100% of the building occupants.