HospitalInspections.org

Based on interview and observations, the facility failed to maintain hazardous areas.


The findings included:


Observation on 5/10/18 at 1:45 PM, revealed the following hazardous areas had penetrations in the 1 hour fire rated wall (drywall construction) that were not repaired per approved fire stop systems. The maintenance director revealed he was not familiar with approved fire stop systems.
Mechanical room by central supply with .
a. a 1 inch copper (medical air) line.

b. a 3/4 inch abandoned steam line.

c. 2 large bundle of low voltage cable.

d. 2 - 1/4 inch metallic flexible conduits.

e. 4 red iron rafters penetrating all walls in the room.

f. 6 - 1/2 inch, a 1 inch, a 1 3/4 inch a 2 inch and 2 - 2 1/2 inch metal electrical conduits.

g. a 2 inch abandoned polyvinyl choride pipe (PVC).

The patient water heater room.
h. 11 unapproved drywall patches on all 4 walls above the ceiling grid.

i. a 3/8 inch metal conduit.
National Fire Protection Association (NFPA)101, 19.3.2.1. (2012 Ed.)
NFPA 101, 8.7.1 (2012 Ed.)
NFPA 101, 8.3.5 (2012 Ed.)
NFPA 101, 8.3.5.1 (2012 Ed.)


The maintenance director was present when the deficiencies were identified and the administrator acknowledged the deficiencies during the exit conference by phone on 5/10/18.

Based on observations, the facility failed to maintain the sprinkler system.


The findings included:

1. Observation on 5/10/18 at 1:30 PM, revealed 4 of 14 corroded sprinklers in the kitchen.
National Fire Protection Association (NFPA) 101, 19.3.5.1 (2012 Ed.)
NFPA 101, 9.7.1.1 (2012 Ed.)
NFPA 13, 26.1 (2010 Ed.)
NFPA 25, 5.2.1.1.2 (2) (2011 Ed.)

The maintenance director was present when the deficiency was identified and the administrator acknowledged the deficiency during the exit conference by phone on 5/10/18.