HospitalInspections.org

The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that 18 inches clearance between the sprinkler head and stored items in the kitchen storage room and between the sprinkler head and hanging pots was not being maintained.


The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that fire walls need additional fire protection at the following locations:
- Near Radiology: Above double doors: The top edge of the wall needs to be sealed. And around the steel beam where it penetrates the fire wall.
- Near Lobby: Above double doors: Around wiring penetrations need to be sealed.
- Near room 111: Above double doors: There is a large penetration that needs to be sealed.
- Hospital's firewall separating it from adjacent facility. Above double doors. There is overlapping gypsum boards where the edge of the gypsum board needs to be sealed.
"Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device." - NFPA 101, 8.3.5.1.

The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 9:00 am to 11:30 am on 07/23/2025 that documentation showing that the yearly fire extinguisher testing was last conducted in 2020. This testing must be done yearly per NFPA 10 - 7.3.1.1.1

The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that the shower curtains in the patient room bathrooms did not have tags indicating that they meet NFPA 701 flame spread and smoke development requirements. Verification that they meet NFPA 701 must be provided, or verification that replacement curtains have been installed that meet NFPA 701.

The inspector observed, while accompanied by the facilities manager, during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that risk assessment documentation was available for review. However, the risk assignments of 1 to 4 per NFPA 99 - A4.1, A4.2 were not being used.

The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that in the medical gas cylinder storage room there was a light switch that was lower that the five-foot requirement per the following.
Locations for central supply systems and the storage of medical gases shall meet the following requirements: (5) Be compliant with NFPA 70, National Electrical Code, for ordinary locations, with electrical devices located at or above 5 feet above finished floor to avoid physical damage - NFPA 99, 5.1.3.3.2(5).

The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that risk assessment documentation for medical gases were not available for review.

The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that items were being stored within six feet of electrical panel boxes.
This is not allowed per "Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage." - NFPA 70, 2012, 110.26(E)


The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that two different electrical room's panel boxes were not labeled per the following requirement.
"Emergency panels shall be distinctively marked so that they are readily identifiable as a component of the essential electrical system." - NFPA 70: 110-22 and 700-9(a). They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.


The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that an emergency electrical generator was less than 10 feet from an electrical transformer. In lieu of moving them further apart, a one-hour fire barrier may be constructed between them. This barrier must be designed by a structural engineer.