HospitalInspections.org

Based on visual observation the facility failed to assure 1 of 2 electrical equipment rooms maintained a 2 hour fire rating in the floor penetrations. were equipped with fire rated doors. This deficiency has the potential to affect 27 of 27 residents.

Findings:

During the facility tour, between the hours of 8:45 a.m., and 2:30 p.m.. the 6th floor electrical room was observed having 2 floor penetrations that were not sealed, also 2 penetrations in the wall were not protected.

Interview with the administrator revealed the facility was not aware the sleeves were not fire rated to maintain the 2 hour required fire protection.
Buildings of 3 of less stories shall have a 1 hour fire rating for all vertical openings and buildings 4 stories or more shall be 2 hour protected.

Based on visual observation the facility failed to assure the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 25. 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 27 of 27 residents.

Findings:

During the facility tour, between the hours of 8:45 a.m. and 2:30 p.m. review of documentation revealed the sprinkler system was not being inspected quarterly by qualified personnel. The last sprinkler inspection was dated 12-31-2014.

Interview with the administrator revealed the facility was not aware a quarterly inspection was required.

Based on visual observation the facilty failed to provide a oxygen storage room which is compliant with the requirements of NFPA 99.
This deficiency has the potential to cause harm to 27 of 27 patients.
During tour of building between the hours of 8:42 a.m. and 2:30 p.m. observation of the oxygen storage room revealed the electrical devices were not placed at least 5 feet from the floor and there were no "No Smoking" signs posted.
NFPA 99
electrical devices shall be located at or
above 1520 mm (5 ft) above finished floor to avoid physical
damage

Based on visual observation and record review, the facility failed to assure the generator was in compliance with the requirements of NFPA 110. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice has the potential to affect 27 of 27 residents.

Findings:

Between the hours of 8:45 a.m. and 2:30 p.m. record review revealed there no written documentation the generator was being run weekly. Also a fire extinguisher was not provided within 30 feet of the generator and "No Smoking" signs were not posted to warn of the fuel tank in the EPS.

Interview with the administrator revealed the facility was not aware the documentation was not complete regarding the inspection/testing of the emergency generator and a fire extinguisher and sign were required.