HospitalInspections.org

Based on record review and staff interview, the facility failed to maintain and test a complete automatic sprinkler system. Findings:

1. The facility records were reviewed on 05/29/2024. The most recent annual sprinkler inspection document was dated 09/18/2023. The facility missed quarterly sprinkler inspections for the fourth quarter of 2023 and the first quarter for 2024.

2. The president of the facility was present during the record review on 05/29/24 and stated they have a contract with the sprinkler company for the quarterly inspections, but the company did not perform the inspections.

Based on observations and staff interview, the facility failed to maintain smoke barrier doors on 4 of 6 halls to close properly to resist the passage of smoke. Findings:

1. The smoke and fire doors throughout the facility. When the doors were closed there was a gap between the doors. These doors would not resist the passage of smoke.

2. The Facility president and the director of nursing were present during the smoke/fire doors inspections and acknowledged the gaps between the doors.

Based on record review and interview, the facility failed to conduct the routine inspections of the corridor doors throughout the facility. Findings:

1. The facility records were reviewed on 05/29/2024 and no documentation was found to show the facility had conducted routine non-rated doors to patient rooms and smoke door inspections.

2. The facility president and director of nursing were interviewed during the record review and they stated they had never performed corridor door inspections.


Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protective's.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)