Inspection Report
Life Safety
Deficiencies: 5
Mar 27, 2023
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety regulations and emergency preparedness requirements.
Findings
The facility was found not in compliance with several fire safety requirements including fire alarm system testing, sprinkler system testing, heating/ventilation/air conditioning maintenance, fire drills, and electrical receptacle testing. Corrective actions and monitoring plans were established to address these deficiencies with compliance expected by 05/19/2023.
Deficiencies (5)
| Description |
|---|
| Fire Alarm System - Testing and Maintenance not maintained in accordance with NFPA 101 and NFPA 72; deficiency affected all control valve tamper switches. |
| Sprinkler System - Maintenance and Testing not maintained in accordance with NFPA 25 and NFPA 101; deficiency affected fire riser testing. |
| Utilities - Gas and Electric equipment not maintained in accordance with NFPA 70; deficiency affected fire dampers. |
| Fire Drills not conducted as required by NFPA 101; deficiency affected fire drills. |
| Electrical Systems - Maintenance and Testing not performed on receptacles at patient bed locations; deficiency affected electrical receptacles near resident beds and exam rooms. |
Report Facts
Date sprinkler system last checked: Not specifically dated but referenced in findings
Number of fire drills missed: 12
Number of fire risers water flow alarm tests missed: 4
Date of compliance: Expected compliance date for all deficiencies is 2023-05-19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cole Julian | Administrator | Named in relation to the Life Safety Code survey and corrective action plan |
Loading inspection reports...
