HospitalInspections.org

Based on observations during tour with facility staff it was determined the facility was not in compliance with the requirements of NFPA-101-Life Safety Code and NFPA-80- Care and Maintenance of Doors.
There shall be no impediment to properly closing the doors to prevent the spread
of fire and the passage of smoke.
Doors shall be operable at all times and provided with positive latching hardware
Every item of equipment or fire door required by code shall be continuously
maintained in proper operating condition.
Door hardware shall be examined frequently and properly maintained.
The fire doors that are prevented from closing in the event of a fire can cause the spread of fire and the passage of smoke which endangering the staff and patients of the facility.

The findings include:


1. At the kitchen area into the cafeteria fast food area, there is a wooden wedge device being used to prop the door open, preventing proper closing and latching. The door closer device is prevented from maintaining the door in the proper closed position.

2. At the service area mail and equipment room, there is no door knob and latching device installed to maintain positive closing. There is no latch keeper plate installed in the door frame to maintain the door latch.

NFPA-101-2000-LSC--19.3.6.1, 19.3.6.3.2, 7.2.1, 7.2., 7.2.9.2, 4.6.12.1
NFPA--80--15.1.2, 15.2.1.1, 15.2.4.1, 15.2.3.3

Based on observation, record review, and tour with facility staff on the day of survey May 11, 2011, it was determined the facility was not in compliance with the requirements of NFPA-101-2000 Life Safety Code, and NFPA-72- Fire Alarm Code Maintenance, Testing, and Inspection.

The findings include :

Observation of the Central Supply storage rooms located at the service corridor area, revealed that there is combustible storage in three rooms.

There are no smoke detection devices installed to activate the fire alarm system or give early warning in the event of a fire or emergency.


NFPA-101-LSC-- CHAP. 19.3.4, CHAP. 9.6
NFPA--72--CHAP. 7.4.1, CHAP. 7.1.2

Based on observation, record review, and tour with facility staff on the day of survey May 11, 2011, the facility was not in compliance with the requirements of NFPA-101-Life Safety Code and NFPA-96, Standard for The Protection of Commercial Cooking Operations.
Chap-11.2.4-- Fusible links shall be replaced at least semi-annually because of installation in grease laden environment and contamination could affect their proper operation.
Chapter 7- at least semi-annually, maintenance shall be conducted and performed by a trained and certified person or contractor.

The findings include:

The date of the last inspection and tag was done on January 24, 2011.
The six month prior inspection was July 2010.
It was observed through inspection of the fusible links that the date of last replacement was 2010.
The fusible links have not been replaced every six months as required.
The fusible links over the deep fryer and cooking areas are coated with excess grease .

A fire could affect all the staff and patients of the facility through the spread of fire and the passage of smoke.



NFPA-101-LSC--19.3.2.6. 9.2.3, 4.6.12.1
NFPA-96--CHAP.--5.1.1, 5.6.4, 7.3.1, 7.3.2, 7.3.2.6, 10.2.1, 10.2.3, 10.2.3.1, 10.2.7,
10.2.7.4, 10.9.2.1, 11.5.1