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OSMOND GENERAL HOSPITAL
Cooking Facilities
Tag No.: K0324
Based on record review and staff interview, the facility failed to have the kitchen range hood exhaust ductwork inspected every six months. This condition did not ensure the cleanliness of the system and increased the potential of a fire in the ductwork.
Findings are:
Record review on 8-30-22, at 10:55 am revealed the kitchen range hood ductwork was not inspected every six months. The ductwork was last inspected and cleaned in October of 2021.
During an interview on 8-30-22, at 10:55 am, Maintenance Staff A confirmed the findings.
NFPA 96, 2011 ed. 11.4
The entire Exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4.
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on documentation review and interview, the facility failed to provide documentation of 5-year internal inspection of the fire sprinkler system piping. This deficient practice would cause the fire sprinkler system to fail to flow the required volume of water and could plug fire sprinklers during a fire emergency.
Findings are:
Record review on 8-30-22 at 11:49 am revealed the lack of documentation of 5-year internal inspection of the fire sprinkler system piping. The last documented test was performed in 2012.
During an interview on 8-30-22 at 11:49 am, Maintenance Staff A confirmed the findings.
Maintenance, Inspection and Testing - Doors
Tag No.: K0761
Based on interview and documentation review, the facility failed to perform annual testing and inspection program to document the integrity and operation of all fire rated doors throughout the facility. These deficient practices failed to ensure that the fire doors would operate as designed to prevent the spread of fire and smoke.
Findings are:
Documentation review on 8-30-22 at 10:20 am revealed that the facility failed to perform required inspections and testing of the fire rated doors throughout the facility less than annually. The last recorded inspection was done on 4-16-21.
During an interview on 8-30-22 at 10:20 am, Maintenance Staff A confirmed the lack of complete fire rated door inspections.
NFPA 80, 2010 Ed. 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.