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EAGLEVILLE HOSPITAL
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on observation and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting one of two levels.
Findings include:
Observation on May 12, 2025, at 11:50 a.m., revealed a sprinkler missing its escutcheon plate, Admissions Office next to supply closet.
Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the missing escutcheon.
Portable Fire Extinguishers
Tag No.: K0355
Based on observation, interview, and document review, it was determined the facility failed to ensure fire alarm inspectors were certified, affecting the entire facility.
Findings include:
Document review on May 12, 2025, at 8:30 a.m., revealed the facility could not provide certification documentation for the inspector that performed the facility's annual portable fire extinguisher inspection in June 2024.
Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the missing documentation.
Subdivision of Building Spaces - Smoke Barrie
Tag No.: K0372
Based on observation and interview, it was determined the facility failed to maintain the fire rating of the smoke barrier walls, affecting one of two levels.
Findings include:
Observations on May 12, 2025, revealed unsealed penetrations of smoke barrier walls in the following locations:
a. 12:25 p.m., open penetrations above entry smoke door, on the first floor, Acute Psychology Unit;
b. 12:45 p.m., open penetration above entry smoke door labeled #34, on the second floor, D2 West.
Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the smoke wall penetrations.
Electrical Systems - Essential Electric Syste
Tag No.: K0918
Based on document review and interview, it was determined the facility failed to maintain and test the generator, affecting the entire facility.
Findings include:
Document review on May 12, 2025, at 8:30 a.m., revealed the facility could not produce documentation of the Annual Fuel Quality Test.
Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the missing fuel quality report.
Electrical Equipment - Power Cords and Extens
Tag No.: K0920
Based on observation and interview it was determined the facility failed to prohibit the improper and unauthorized use of electrical devices, affecting one of two levels.
Findings include:
Observation on May 12, 2025, at 12:30 p.m., revealed a refrigerator plugged into a power strip, the first EVS Administration office.
Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the unauthorized electrical device.
Gas Equipment - Cylinder and Container Storag
Tag No.: K0923
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of medical gas rooms, in sprinklered locations, affecting one of two levels.
Findings include:
Observation on May 12, 2025, at 11:20 a.m., revealed, on the first floor, in room 112 Oxygen Storage Room door lacked a self-closer.
Exit interview with the Chief Operating Officer on May 12, 2025, at 2:00 p.m., confirmed the oxygen storage door deficiency.