HospitalInspections.org

Based on visual observation, the facility failed to assure the annual inspection and testing of fire doors in accordance with NFPA 80 were performed. This deficient practice could potentially affect 16 of 16 residents in the facility.


Findings:

During the facility tour and record review, on October 23,2018 between the hours of 8:30 am to 3:00 pm review of facility records revealed the facility had no documentation showing the annual inspection of the fire doors had been performed.

Interview with the administrator revealed the facility was not aware the annual inspection was required on the fire doors during the exit interview.








Based on visual observation, the facility failed to assure the annual inspection and testing of fire doors in accordance with NFPA 80 were performed. This deficient practice could potentially affect 16 of 16 residents in the facility.


Findings:

During the facility tour and record review, on October 23,2018 between the hours of 8:30 am to 3:00 pm review of facility records revealed the facility had no documentation showing the annual inspection of the fire doors had been performed.

Interview with the administrator revealed the facility was not aware the annual inspection was required on the fire doors during the exit interview.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 16 of 16 residents.

Findings:

During the facility tour and the record review, on October 23, 2018 between the hours of 8:30 am to 3:00 pm review of the facility's fire alarm documents revealed the required 2 year sensitivity test for the smoke detectors had not been performed. NFPA 72 14.4.5.3.2 requires smoke detectors to be tested for sensitivity on alternate years.

Interview with the administrator revealed the facility was not aware that the required inspections had not been conducted on the smoke detectors at the exit interview.

Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 16 of 16 residents.

Findings:

During the facility tour, on October 23, 2018 between the hours of 8:30 am and 3:00 pm review of the facility's sprinkler inspection documents revealed there was no record of the NFPA 25 required 5 year internal sprinkler pipe inspection for wet and dry systems.

Interview with the administer revealed the facility was not aware that the 5 year internal pipe inspection was required for the sprinkler system at the exit interview.

Based on visual observation this sprinklered facility failed to assure that the smoke compartmental of the membrane between the egress corridor and rooms, adjacent to the egress corridor, were not compromised. Repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. This deficient practice had the potential to affect 16 of 16 residents.

Findings:

During the facility tour, on October 23, 2018 between the hours of 8:30 am and 3:00 pm the decoration closet was observed with multiple penetrations that had not been sealed due to the previous construction project in the building.

Interview with the administrator revealed the facility was not aware of the penetrations in this corridor closet that would allow the transfer of smoke into the exit corridor..

Based on visual observation, the facility failed to assure the emergency prime mover generator was equipped with a remote emergency shut off . NFPA 110 requires generator installations to have a remote manual stop station.

Findings:

During the facility tour on October 23, 2018 between the hours of 8:30 am and 3:00 pm it was observed that the emergency generator did not have a remote shut off in case of a emergency.

NFPA 110:5.6.5.6 -Requires all installations to have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover (generator), where so installed, or elsewhere on the premises where the prime mover (generator) is located outside the building and shall be appropriately identified.

Interview with the administrator revealed the facility was not aware a remote shut off was required for the generator at the exit interview.