HospitalInspections.org

Based on record review and interview staff it was determined the facility failed to provide documentation of a local fire inspection. An annual local fire inspection ensures the building remains within the building codes and fire safety codes. Failure to have an annual fire inspection could bring harm to patients and staff during an emergency.

CMS State Operations Manuel Appendix A- Interpretive Guidelines §482.11 The hospital must ensure that all applicable Federal, State and local law requirements are met.. The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. NFPA 101 2012 Life Safety Code Section 4.6.12. Maintenance, Inspection, and Testing. 4.6.12 Maintenance, inspection and testing shall be performed under supervision of a responsible person who shall ensure that testing, inspection, and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.


Findings include:

Records review on Aug 17, 2021 revealed the facility failed to provide required documentation of an annual local fire inspection since 2015.

Employees #2, #3, #5, #6 and #15 acknowledged during the exit conferance that the facility failed to provide required documentation of an annual local fire inspection.

Based on Observation, the facility failed to test the fire alarm system and Porter Dry Chemical system for the monthly and annual requirements for the facility. Failure to test the fire alarm system could cause harm to staff and residents during an emergency.

NFPA 101, Life Safety Code, 2012 Edition, Chapter 9, Section 9.6.1.3 "A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use". NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition, Chapter 14, Section 14.2.2.1, "The property or building or system owner or the owner ' s designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system". Chapter 26, Section 26.3.5.2.2 "The subsidiary facility shall be inspected at least monthly by central station personnel for the purpose of verifying the operation of all supervised equipment, all telephones, all battery conditions, and all fluid levels of batteries and generators". NFPA 72, National Fire Alarm and Signaling Code, Section14.6.2.1, Records shall be retained until the next test and fore 1 year thereafter. CMS requires 3 years.
NFPA 72 Chapter 14, section 14.2.5 Releasing Systems.
Requirements pertinent to testing the fire alarm systems initiating fire suppression system releasing functions shall be covered by 14.2.5.1 through 14.2.5.6. and must be inspected in accordance with section 14.3 Inspection which requires Monthly and Annual inspection amd service.


Findings include:

During review of the facility's documentation on Aug 17, 2021, There was no documentation of a monthly testor annual testing of the following sysytems:
1.The fire alarm system is missing monthly testing.
2.The Porter dry chemical system has not had a monthly or annual since it was installed the facility claims was installed three years earlier.


Employees #2, #3, #5, #6 and #15 acknowledged during the exit conferance that the facility failed conduct the required monthly and annual testing.

Based on record review it was determined that the facility failed to the monthly inspection for the facility's sprinklers systems. Failing to perform the required inspections may cause harm to patients and staff


NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition, "Water Based Extinguishment Systems," requires monthly, quarterly and annual testing of automatic sprinkler systems.
Findings Include:

Observations while on tour Aug 16-19, 2021 revealed the facility failed to show proof of monthly testing of the sprinkler systems in accordance with NFPA 25 Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems.


Employees #2, #3, #5, #6 and #15 acknowledged during the exit conferance that the facility failed conduct the required monthly testing of the sprinklers systems.

Based on observation it was determined that the facility did not have written documentation of the annual inspection and testing of the kithchen roll-up door openings in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protective's ". Failing to inspect and test fire rated door assemblies in accordance with NFPA 80 annually could cause harm to the patients.

NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware,including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code.

NFPA 80 Section 5.2* Inspections Section 5.2.1* Fire door assemblies shall be inspected and tested not less than annually , and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

Findings include:

Observation while on tour and during review of facility documentation conducted on Aug 16-19, 2021 it was determined the facility did not have written records of the Annual Inspection and Testing of the kitchen roll-up door opening in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protective's.

Employees #2, #3, #5, #6 and #15 acknowledged during the exit conferance that the facility failed conduct the NFPA 80 required testing of the kitchen roll-up door.

Based on observation and staff interview, the facility failed to ensure a remote stop or kill switch for the generator was installed. This affected the entire facility and could result in a loss of power due to a generator malfunction during an emergency power outage. Failure to have an emergency stop on the generator could cause a fire or harm to the residents and/or staff.


Code reference: NFPA 110 2010 Edition; Standard for Emergency and Standby Power Systems 5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation, located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. A.5.6.5.6 For systems located outdoors, the manual shut-down should be located external to the weatherproof enclosure and should be appropriately identified.

Findings include:

Obervations while on tour conducted on Aug 16-19, 2020 it was revealed the facility generator did not have remote stop or kill switch.

Employees #2, #3, #5, #6 and #15 acknowledged during the exit conferance that the facility failed install a remote stop switch for the emergency deisel generator