HospitalInspections.org

Based on record review, it was determined that the facility failed to conduct all required testing on the automatic sprinkler system.

The findings include:

Record review on September 2, 2014 at 11:45 a.m. revealed no 5 year gauge replacement or calibration has been conducted on the automatic sprinkler system.
NFPA 25 2-3.2

This finding was verified by the maintenance director and acknowledged by the administrator during the exit conference on September 2, 2014.

Based on observation, it was determined that the facility failed to construct and install piped in medical gasses and its components in accordance with NFPA 99, Standards for Health Care Facilities.

The findings include:

1. Observation on September 2, 2014 at 2:30 p.m. revealed the oxygen manifold room is not in a location that serves only oxygen storage and the oxygen manifold and is not free of combustible materials.
NFPA 99 4-3.1.1.2(a)2, NFPA 4-3.1.1.2(a)5
2. Observation on September 2, 2014 at 2:40 p.m. revealed the oxygen manifold room and oxygen storage room that stores approximately 30 H-cylinders and approximately 20 e-cylinders of oxygen and is not in a 1 hour fire rated room with a 45 minute fire rated door.
NFPA 99 4-3.1.1.2(a)2

These findings were verified by the maintenance director and acknowledged by the administrator during the exit conference on September 2, 2014.

Based on record review, it was determined that the facility failed to conduct all required testing on the automatic sprinkler system.

The findings include:

Record review on September 2, 2014 at 11:45 a.m. revealed no 5 year gauge replacement or calibration has been conducted on the automatic sprinkler system.
NFPA 25 2-3.2

This finding was verified by the maintenance director and acknowledged by the administrator during the exit conference on September 2, 2014.

Based on observation, it was determined that the facility failed to construct and install piped in medical gasses and its components in accordance with NFPA 99, Standards for Health Care Facilities.

The findings include:

1. Observation on September 2, 2014 at 2:30 p.m. revealed the oxygen manifold room is not in a location that serves only oxygen storage and the oxygen manifold and is not free of combustible materials.
NFPA 99 4-3.1.1.2(a)2, NFPA 4-3.1.1.2(a)5
2. Observation on September 2, 2014 at 2:40 p.m. revealed the oxygen manifold room and oxygen storage room that stores approximately 30 H-cylinders and approximately 20 e-cylinders of oxygen and is not in a 1 hour fire rated room with a 45 minute fire rated door.
NFPA 99 4-3.1.1.2(a)2

These findings were verified by the maintenance director and acknowledged by the administrator during the exit conference on September 2, 2014.