HospitalInspections.org

.
Based on document review and staff interview, the facility failed to provide record of a 4 hour test every 3 years in accordance with the 2012 NFPA 101, Life Safety Code and the 2010 NFPA 110, Standard for Emergency and Standby Power Systems. The failure to perform a testing as required could result in a power loss during an emergency. The deficiency affected facility-wide reliability of the emergency power system. The findings were:

Document review and staff interview on 5/18/2022 at 9:28 AM with the maintenance manager revealed that no record of a 4 hour test of the generator every 3 years was available.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were not aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101 Sections 19.5.1, 9.1, and
9.1.3.1
2010 NFPA 110 Section 8.4.9
.

.
Based on observation and staff interview, the facility failed to maintain doors with self-closing devices in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain doors with self-closing devices as required could increase the risk of fire spread during an emergency resulting in injury or death. The deficiency affected one (1) of many doors with a self-closing device throughout the facility. The findings were:

Observation on 5/17/2022 at 3:32 PM at the mechanical room by the board room revealed that the self-closing door failed to operate as designed. When drop tested with no initial motion the door failed to shut and latch.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.3.2.1.3, 7.2.1.8
.

.
Based on observation and staff interview, the facility failed to perform a smoke detector sensitivity test every two years in accordance with the 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to test smoke detector sensitivity could lead to delayed detection of smoke in an emergency. The deficiency affected the entire building. The findings were:

Document review and staff interview on 5/18/22 at 9:05 AM with the maintenance manager found that the smoke detector sensitivity testing had not been performed in more than two years.

Interview with the maintenance manager at the time of observations acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

Ref: 2010 NFPA 72, Table 14.4.5(15)(i), 14.4.5.3.2
.

.
1. Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the 2010 NFPA 13, Standard for the Installation of Sprinklers. Failure to properly maintain the fire sprinkler system could result in injury or death in the event of a fire. The deficiency affected one (1) of numerous rooms. The findings were:

Observation on 5/17/22 at 2:35 PM in the rehab lobby revealed an obstruction to the sprinkler head. The obstruction was an exit sign located within the vicinity of the sprinkler head that would interrupt proper development of the spray pattern.

Interview with the maintenance manager at the time of observations acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2010 NFPA 13, Sections: 8.6.5

2. Based on observation and staff interview the facility failed to install sprinklers in all required areas in accordance with the 2012 NFPA 101, Life Safety Code. Failure to the install sprinklers in all required areas could result in injury or death in the event of a fire. The deficiency affected one (1) of several smoke compartments. The findings were:

Observation on 5/17/22 at 4:55 PM in the rear hazardous materials storage revealed the storage area did not contain a sprinkler system as required.

Interview with the maintenance manager at the time of observations acknowledged the deficiency, and indicated they were not aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 13, Sections: 19.3.5.1, 19.3.5.3
.

.
Based on document review and staff interview, the facility failed to provide record of fire damper testing conducted in accordance with the 2012 NFPA 101, Life Safety Code, the 2012 NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, and the 2010 NFPA 80, Standard for Fire Doors and Other Opening Protectives. The failure to perform fire damper testing as required could result in the spread of smoke and fire during an emergency. The deficiency affected facility-wide reliability of the fire dampers. The findings were:

Document review and staff interview on 5/18/2022 at 9:15 AM with the maintenance manager revealed that no record of testing of the fire dampers from the past six (6) years was available.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were not aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101 Sections 19.5.2.1, 9.2
2012 NFPA 90A Section 5.4.8.1
2010 NFPA 80 Section 19.4.1.1
.

.
Based on observation and staff interview, the facility failed to provide portable space heaters in accordance with the 2012 NFPA 101, Life Safety Code. Failure to provide portable space heaters as required could increase the risk of fire and injury. The deficiency affected one (1) of multiple rooms in the facility. The findings were:

Observation on 5/17/2022 at 3:20 PM in the HR office revealed a portable space heater. The area is a non-sleeping staff area. However, no documentation was available to determine the maximum temperature of the heating elements.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101, Section 19.7.8
.

.
Based on observation and staff interview, the facility failed to provided ventilation in oxygen rooms in accordance with the 2012 NFPA 101, Life Safety Code. The failure to provide ventilation in oxygen rooms as required could result in injury or death in an emergency. The deficiency affected one (1) smoke compartment in the facility. The findings were:

Observation on 5/17/22 at 4:45 PM in the medical gas storage and manifold room revealed that the room was provided with natural ventilation via one louver located within 1 foot of the floor. Per NFPA 99, ventilation must be provided either per natural ventilation including two (2) openings within one foot of the floor and ceiling, or via mechanical ventilation with an inlet drawing from within one foot of the floor. The room contained over thirteen thousand (13,000) cubic feet of oxygen. The room also did not have a method for providing indirect heating to ensure that minimum temperature levels are maintained.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were not aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 99, Sections: 9.3.7.5; 9.3.7.5.2, 9.3.7.5.3, 9.3.7.5.3.7
.

.
Based on document review and staff interview, the facility failed to provide record of a 4 hour test every 3 years in accordance with the 2012 NFPA 101, Life Safety Code and the 2010 NFPA 110, Standard for Emergency and Standby Power Systems. The failure to perform testing as required could result in a power loss during an emergency. The deficiency affected facility-wide reliability of the emergency power system. The findings were:

Document review and staff interview on 5/18/2022 at 9:28 AM with the maintenance manager revealed that no record of a 4 hour test of the generator every 3 years was available.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were not aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101 Sections 19.5.1, 9.1, and
9.1.3.1
2010 NFPA 110 Section 8.4.9
.

.
Based on observation and staff interview, the facility failed to provide electrical equipment in accordance with the 2012 NFPA 101, Life Safety Code and the 2011 NFPA 70 National Electrical Code. The failure to provide electrical equipment as required could result in injury or death due in an emergency. The deficiency affected one (1) of numerous rooms in the facility. The findings were:

Observation on 5/17/2022 at 2:45 PM in the pharmacy revealed that an extension cord was being used to provide power to the medicine refrigerator. The extension cord was being used as a substitute for fixed wiring as there was no outlet providing power during an emergency nearby the location of the refrigerator.

Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement.

Interview with the facility administrator at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101, Section 9.1.2
2011 NFPA 70, Section 400.8