HospitalInspections.org

Based on observation and staff interview, the facility did not properly maintain enclose stairways used for exits and smoke proof enclosures in accordance with NFPA 101 (2012), Life Safety Code, section 7.1.3.2.1. These deficient findings could an isolated impact on the residents within the facility.

Findings include:

On 04/09/2024 between 0900 and 1300, it was revealed by observation that storage materials had been placed in the emergency exit stairwell under the staircase that leads to the penthouse.

An interview with the Director of Facility and Supply Services verified these deficient findings at the time of discovery.

Based on a review of the available documentation and staff interview, the facility failed to implement a fire evacuation plan per NFPA 101 (2012 edition), Life Safety Code, section 9.6.1.6. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 04/09/2024 between 0900 and 1300, it was revealed by a review of available documentation that the facility could not provide a copy of an Out of Service Policy indicating that the facility would contact the State Fire Marshals Office (Authority having jurisdiction) in the event on a fire alarm outage lasting longer than four (4) hours in a 24-hour period.

An interview with the Director of Facility and Supply Services verified these deficient findings at the time of discovery.

Based on observation, a review of available documentation, and staff interview, the facility failed to inspect and maintain the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, sections 5.1.1.2, and 5.3.2.1. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 04/09/2024 between 0900 and 1300, it was revealed by a review of available documentation the facility failed to perform the five (5) year sprinkler system testing.

An interview with the Director of Facility and Supply Services verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain spacing between storage and the sprinkler system per NFPA 101 (2012 edition), Life Safety Code, Section 9.7.5, NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 5.2.1.2, and NFPA 13 (2010 edition), Standard for the Installation of Sprinkler Systems, Sections 8.6.5.3.2 and 8.15.9. These deficient findings could a patterned impact on the residents within the facility.

Findings include:

On 04/09/2024 between 0900 and 1300, it was revealed by observation that storage materials had been placed on a storage rack, bringing the storage materials within the required 18 inch clearance area under the sprinkler heads. These obstructions were found in BioMed storage room.

An interview with the Director of Facility and Supply Services verified these deficient findings at the time of discovery.

Based on document review and staff interview, the facility did not properly implement a fire watch protocol for when the fire alarm system is out of service for more than 10 hours in a 24-hour period, according to NFPA 101 2012 edition, Life Safety Code, section 19.3.5.1, 9.7.5, and NFPA 25 2017 edition, Installation, Test and Maintenance of Water Based System, section 15.5.2. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 04/09/2024 between 0900 and 1300, it was revealed by documentation review that the facility failed to provide an out of service policy that indicated that the facility would contact the State Fire Marshals Office (Authority having jurisdiction) in the event on a fire sprinkler system outage lasting longer than ten (10) hours in a 24-hour period. .

An interview with the Director of Facility and Supply Services verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to inspect fire dampers per NFPA 101 (2012 edition), Life Safety Code, section 8.5.5.4.2, and NFPA 105 (2010 edition), Standard for Smoke Door Assemblies and Other Opening Protectives, section 6.5.2, 6.5.11, and 6.5.12. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 04/09/2024 between 0900 and 1300, it was revealed by a review of available documentation that the facility could not provide a fire damper inspection report.

An interview with the Director of Facility and Supply Services verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to conduct fire drills under varied times and conditions per NFPA 101 (2012 edition), Life Safety Code, sections 19.7.1.6, 4.7.4, and 4.6.1.1. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 04/09/2024 between 0900 and 1300, it was revealed by a review of available documentation that fire drills did not meet the varying time requirement:

first shift - first quarter 01/25/24 @ 10:35 and second quarter 04/24/23 @ 10:30.

third shift - fourth quarter 12/21/23 @ 0500, first quarter 3/22/24 @ 0520 and second quarter 06/29/23 @ 04:45

An interview with the Maintenance Director verified this deficient finding at the time of discovery.