HospitalInspections.org

Based on record review, the facility failed to provide a properly maintained fire alarm system as required by NFPA 72 Table 14.3.1 and section 14.4.5.3.2. This deficiency affected the entire facility on day of survey.

Findings include:

On 7/19/22 at 1:45 PM, observation and record review revealed the facility was unable to provide the years 2021 or 2022 documentation of annual and sensitivity inspection of the fire alarm system.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 7/19/22.

Based on the review of documentation, the facility failed to properly document records of testing the sprinkler system as required by NFPA 25 Table 2-1 and section 2-2.6. This deficient practice had potential of affecting the entire facility on the day of facility survey.

Findings Include:

On 7/19/22 at 1:30 PM, the facility could not produce the documentation for quarterly inspection of the fire sprinkler system for calendar years of 2021 and 2022.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 7/19/22.

Based on the observation and document review, the facility failed to provide the fire drill in accordance with NFPA 110 section 19.7.1.6 and 19.7.1.7. This standard deficiency affected entire facility on the day of the survey.

Findings Include:

On 7/19/22 at 1:42 PM, observation and document review revealed no documentation of fire drills for all shifts during 2nd quarter of 2022.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 7/19/22.

Based on observations, the facility failed to provide all the generator required components as accordance to NFPA 110 section 5.6.6 and NFPA 99 section 6.4.1.1.17. The deficient practice affected the entire facility on day of survey.

Findings Include:

On 7/19/22 at 10:50 AM, observation revealed the generator lacked a complete remote annunciator panel in a constantly monitored location of the facility (ex. Nurses station or receptionist desk ...).

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 7/19/22.

Based on the review of documentation, the facility failed to properly document records of testing the generator annually as directed by NFPA 110 section 8.4.2, NFPA 99 sections 6.4.4.1.1.3 and 6.4.4.2. This deficient practice had potential of affecting the entire facility on the day of facility survey.

Findings Include:

On 7/19/22 at 1:35 PM, the facility could not produce most the documentation for monthly load test of the generator with the calendar years of 2021 and 2022.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 7/19/22.