HospitalInspections.org

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Based on observation and interview, the facility failed to maintain the fire alarm remote annunciator per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, 10.16.3*

Findings include:

On 6/27/2018, during a tour of the facility from 12:45 pm to 3:45 pm, the fire alarm remote annunciator was not readily accessible to responding personnel.
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Based on review of documentation and interview, the facility failed to maintain the automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.5, 9.7.7, and 9.7.8
2011 NFPA 25, Table 5.1.1.2

Findings include:

On 6/28/2018, during a tour of the facility from 8:15 am to 10:45 am, the facility failed to provide all of the quarterly automatic sprinkler inspection records for the past 12 months. Only the annual inspection conducted on 03/23/2018 was provided.

A member of the maintenance staff and administrator was present, when this deficiency was identified.

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Based on review of documentation and interview, the facility failed to maintain the automatic sprinkler system per the requirements of:

2012 NFPA 101, 19.3.5.1, 9.7.5, 9.7.7, and 9.7.8
2011 NFPA 25, Table 5.1.1.2

Findings include:

On 6/28/2018, during a tour of the facility from 8:15 am to 10:45 am, the facility failed to provide all of the quarterly automatic sprinkler inspection records for the past 12 months. Only the annual inspection conducted on 03/23/2018 was provided.

A member of the maintenance staff and administrator was present, when this deficiency was identified.

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Based on observation and interview, the facility failed to prohibit portable space heating devices per the requirements of:

2012 NFPA 101, 19.7.8

Findings include:

On 6/27/2017, during a tour of the facility from 12:45 pm to 3:45 pm, the surveyor observed a portable space heating device (unplugged) under a desk in the Physical Therapy Office.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain the generator's remote annunciator per the requirements of:

2012 NFPA 99, 6.4.1.1.17

Findings include:

On 6/27/2018, during a tour of the facility from 12:45 pm to 3:45 pm, the surveyor observed the generator's remote annunciator was not in a location readily observed by operating personnel at a regular work station.
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Based on observation and interview, the facility failed to maintain the oxygen storage area per the requirements of:

2012 NFPA 99, 11.6.5.3

Findings include:

On 6/27/2017, during a tour of the facility from 12:45 pm to 3:45 pm, the surveyor observed the empty oxygen cylinders were not marked to avoid confusion and delay.

A member of the maintenance staff was present when this deficiency was identified.