HospitalInspections.org

During the survey tour of 03/17/2015, between the hours of 1200 and 1430, while accompanied by the Plant Manager, through observation and staff interview, it was discovered that the facility failed to maintain the ability of doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. In the event of a fire, this would allow for the passage of smoke and/or flames into or out of the stairwell meant to be protected by self-closing doors. This finding was acknowledged by the Plant Manager.

The findings include but are not limited to:

1. Cross-Corridor fire doors from near the Kitchen failed to close and latch when tested. Frame was discovered to be missing locking hardware and smoke seal.

Based upon staff interview, observation and record review during the survey of the facility on 03/17/2015, between the hours of 0930 and 1100, while accompanied by the Plant Manager, it was discovered that the facility has failed to maintain the automatic fire sprinkler system in a reliable operating condition as required by NFPA 25. This could result in a failure of the proper operation of the automatic fire sprinkler system with the potential of fire spreading unchecked, placing patients, visitors and staff at risk. This finding was acknowledged by the Plant Manager.

The findings include but are not limited to:

1. The AFSS is overdue for 5 year testing (last completed 01/2010).
2. There is no documentation of a quarterly inspection of the automatic fire sprinkler system for 3rd Quarter 2014 (last quarterly inspection was completed 03/07/14).

Based upon staff interview, observation and record review during the survey of the facility on 03/17/2015, between the hours of 0930 and 1100, while accompanied by the Plant Manager, it was discovered that the facility has failed to maintain the automatic fire sprinkler system in a reliable operating condition as required by NFPA 25. This could result in a failure of the proper operation of the automatic fire sprinkler system with the potential of fire spreading unchecked, placing patients, visitors and staff at risk. This finding was acknowledged by the Plant Manager.

The findings include but are not limited to:

1. The AFSS is overdue for 5 year testing (last completed 01/2010).
2. There is no documentation of a quarterly inspection of the automatic fire sprinkler system for 3rd Quarter 2014 (last quarterly inspection was completed 03/07/14).
3. Report for riser covering E.D. (existing) indicates trouble with the Tamper Switch.

During the survey tour of 03/17/2015, between the hours of 1200 and 1430, while accompanied by the Plant Manager, through observation and staff interview, it was discovered that the facility failed to maintain their emergency generator in accordance with the requirements of National Fire Protection Association (NFPA) Standard 110. This could compromise the ability of the emergency power supply to be shut down safely in the event of a generator malfunction, placing staff at risk. These findings were acknowledged by the Plant Manager.

The findings are as follows:
1. Generator is lacking a Remote Stop Switch (per NFPA 110 3-5.5.6)

During the survey tour of 03/17/2015, between the hours of 1200 and 1430, while accompanied by the Plant Manager, through observation and staff interview, it was discovered that the facility failed to maintain the ability of doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. In the event of a fire, this would allow for the passage of smoke and/or flames into or out of the stairwell meant to be protected by self-closing doors. This finding was acknowledged by the Plant Manager.

The findings include but are not limited to:

1. Cross-Corridor fire doors from near the Kitchen failed to close and latch when tested. Frame was discovered to be missing locking hardware and smoke seal.

Based upon staff interview, observation and record review during the survey of the facility on 03/17/2015, between the hours of 0930 and 1100, while accompanied by the Plant Manager, it was discovered that the facility has failed to maintain the automatic fire sprinkler system in a reliable operating condition as required by NFPA 25. This could result in a failure of the proper operation of the automatic fire sprinkler system with the potential of fire spreading unchecked, placing patients, visitors and staff at risk. This finding was acknowledged by the Plant Manager.

The findings include but are not limited to:

1. The AFSS is overdue for 5 year testing (last completed 01/2010).
2. There is no documentation of a quarterly inspection of the automatic fire sprinkler system for 3rd Quarter 2014 (last quarterly inspection was completed 03/07/14).

Based upon staff interview, observation and record review during the survey of the facility on 03/17/2015, between the hours of 0930 and 1100, while accompanied by the Plant Manager, it was discovered that the facility has failed to maintain the automatic fire sprinkler system in a reliable operating condition as required by NFPA 25. This could result in a failure of the proper operation of the automatic fire sprinkler system with the potential of fire spreading unchecked, placing patients, visitors and staff at risk. This finding was acknowledged by the Plant Manager.

The findings include but are not limited to:

1. The AFSS is overdue for 5 year testing (last completed 01/2010).
2. There is no documentation of a quarterly inspection of the automatic fire sprinkler system for 3rd Quarter 2014 (last quarterly inspection was completed 03/07/14).
3. Report for riser covering E.D. (existing) indicates trouble with the Tamper Switch.

During the survey tour of 03/17/2015, between the hours of 1200 and 1430, while accompanied by the Plant Manager, through observation and staff interview, it was discovered that the facility failed to maintain their emergency generator in accordance with the requirements of National Fire Protection Association (NFPA) Standard 110. This could compromise the ability of the emergency power supply to be shut down safely in the event of a generator malfunction, placing staff at risk. These findings were acknowledged by the Plant Manager.

The findings are as follows:
1. Generator is lacking a Remote Stop Switch (per NFPA 110 3-5.5.6)