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Tag No.: K0353
Based on observation and interview, it was determined that the facility failed to maintain sprinkler system components on one of one floors.
Findings include:
1. Observation on July 14, 2021, between 10:30 a.m. and 10:50 a.m., revealed the following sprinkler system deficiencies:
A. (10:30 a.m.) above Med Surg kitchen fires doors, wires on sprinkler pipe;
B. (10:38 a.m.) patient room 21, had missing escutcheon around sprinkler head;
C. (10:50 a.m.) above ceiling at room 8, wires on sprinkler pipe.
Interview with the maintenance supervisor on July 14, 2021, at 10:50 a.m., confirmed the sprinkler system deficiencies existed.
2. Documentation review and interview on July 14, 2021 revealed the following Sprinkler testing deficiencies:
A. 10:00 a.m. facility could not find documentation showing an internal 5 year pipe inspection
B. 10:00 a.m. facility could not find documentation showing internal 5 year valve inspection
Interview with Maintenance supervisor on July 14,2021 at 10:01 a.m. confirmed documentation was not available.
Tag No.: K0372
Based on observation and interview, it was determined that the facility failed to maintain the fire rating of the smoke barrier walls on one of two floors.
Findings include:
Observation on July 14, 2021 at 11:44 a.m. revealed the following two quarter size penetration in the smoke wall above the double doors near the conference room.
Interview with Maintenance Supervisor on July 14, 2021 stated above confirmed the existence of this condition.
Tag No.: K0918
Based on observation and interview it was determined that the facility failed to install and maintain the emergency generator per NFPA 110-5.6.5.6, on one of one emergency generators.
Findings include:
Observation on July 14, 2020, at 11:18 a.m., revealed the emergency generator, located inside the mechanical room, lacked a remote emergency shut off button, located on the exterior of the emergency generator room.
Interview with the maintenance supervisor on July 14, 2020, at 11:18 a.m., confirmed the emergency generator lacked a remote emergency shut off button, located on the exterior of the emergency generator room.