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Tag No.: K0052
Based on observation and interview with staff, the facility failed to provide a fire alarm system
annual inspection that included testing all connected equipment per applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings,
The annual inspection conducted on 1-12-2012 failed to include testing of the combination fire and smoke dampers.
Tag No.: K0056
Based on observation and interview with staff, the facility failed to provide complete documentation for the automatic sprinkler system test in compliance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 19-3.5, Findings,
The annual inspection report for a test conducted on 10/25/2011 did not have the owner's section completed and was not signed by a hospital representative.
Tag No.: K0072
Based on observation and interview with staff, the facility failed to provide means of egress that are continuously maintained free of all obstructions or impediments. Findings:
Furnishings; such as beds, tables, equipment and vending machines are located in corridors, creating obstructions and impediments to full instant access as a means of egress in the case of fire or other emergency.
Tag No.: K0130
Based on observation and interview with staff (Director of Engineering and CEO), the facilities' emergency preparedness management plan failed to provide detail to demonstrate the facilities' ability to provide continuous service in a disaster as required by NFPA 99 1999 edition, 11-5.3.2 Continuity of Essential Building Systems. Findings,
The plan provided by the facility is only an outline and does not provide details on how the hospital will provide uninterrupted services.