HospitalInspections.org

Based on observation, staff interview and document review it was determined the facility failed to maintain and test the fire alarm system as required by National Fire Protection Association (NFPA) 72. Facility census 5.

Findings include:

1. Document review conducted on 11/07/17 between the hours of 8:00 a.m. and 12:00 p.m. revealed the facility failed to conduct a smoke detector sensitivity test in accordance with NFPA 72.

2. The above finding was discussed with the Administrator and the Director of Support Services on 11/07/17 at approximately 4:00 p.m. and agreed the deficiency needed corrected.

Based on observation, staff interview and a facility inspection tour it was determined the facility failed to maintain and test the sprinkler system in accordance with National Fire Protection Association (NFPA) 25. Facility census 5.

Findings include:

1. Observation during the facility inspection tour conducted on 11/07/17 between the hours of 1:00 p.m. and 4:00 p.m. revealed the facility failed to maintain and test the automatic sprinkler system in accordance with NFPA 25. Communication wires were noted on the sprinkler piping above the dining room ceiling, above the kitchen ceiling, above the corridor ceiling next to the acute care nurse station, above the corridor ceiling next to physical therapy and above the x-ray corridor ceiling.

2. The above findings were discussed with the Administrator and the Director of Support Services 11/07/17 at approximately 4:00 p.m. and agreed the deficiencies needed corrected.

Based on staff interview and document review it was determined the facility failed to maintain receptacles located at patient bed locations in accordance with National Fire Protection Association (NFPA) 99. Facility census 5.

Findings include:

1. Document review conducted on 11/07/17 between the hours of 8:00 a.m. and 12:00 p.m. revealed the facility failed to conduct testing of receptacles at patient bed locations in accordance with NFPA 99.

2. The above finding was discussed with the Administrator and the Director of Support Services on 11/07/17 at approximately 4:00 p.m. and agreed the deficiency needed corrected.

Based on staff interview and document review it was determined the facility failed to conduct Essential Electric System Maintenance and Testing in accordance with National Fire Protection Association (NFPA) 110. Facility census 5.

Findings include:

1. Document review conducted on 11/07/17 between the hours of 8:00 a.m. and 12:00 p.m. revealed the facility failed to conduct a three (3) year, four (4) hour generator load test in accordance with NFPA 110.

2. The above finding was discussed with the Administrator and the Director of Support Services on 11/07/17 at approximately 4:00 p.m. and agreed the deficiency needed corrected.

Based on staff interview and document review it was determined the facility failed to conduct testing and maintenance of patient-care related electrical equipment in accordance with National Fire Protection Association (NFPA) 99. Facility census 5.

Findings include:

1. Document review conducted on 11/07/17 between the hours of 8:00 a.m. and 12:00 p.m. revealed the facility failed to conduct maintenance and testing of patient-care related equipment in accordance with NFPA 99.

2. The above finding was discussed with the Administrator and the Director of Support Services 11/07/17 at approximately 4:00 p.m. and agreed the deficiency needed corrected.