HospitalInspections.org

Based on observations, the facility failed to properly protect corridors from use areas as directed by NFPA 101 chapter 19.3.6.2.1.

Findings Include:

On January 9, 2015 between 1:00 p.m. and 2:00 p.m., the maintenance person and surveyor found numerous randomly located unsealed penetrations in the corridor walls above the lay-in ceiling.

19.3.6.2.1*
Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

Based on observations, the facility failed to properly protect hazardous areas.

Findings Include:

On January 9, 2015 at 2:15 p.m., the maintenance person and surveyor found the following hazardous areas to be lacking automatic door closers;

1) Lab
2) Clean utility
3) Medical records

Based on observations, the facility failed to properly maintain fire extinguishers as per
NFPA 10 4 - 4.3, and NFPA 10 4-4.4.2.

Findings Include:

On January 9, 2015 at 11:20 a.m., the maintenance person and surveyor found the K class fire extinguisher
located in the kitchen to be passed due for a six year inspection. The extinguisher was dated 2003.


NFPA 10 4-4.3
Six-Year Maintenance.
Every 6 years, stored-pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures. The removal of agent from halon agent fire extinguishers shall only be done using a listed halon closed recovery system. When the applicable maintenance procedures are performed during periodic recharging or hydrostatic testing, the 6-year requirement shall begin from that date.

4-4.4.2* Verification of Service (Maintenance or Recharging).
Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged (see 4-5.5) shall have a " Verification of Service " collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The " Verification of Service " collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch.
Exception No. 1: Fire extinguishers undergoing maintenance before January 1, 1999.
Exception No. 2: Cartridge/cylinder-operated fire extinguishers do not require a " Verification of Service " collar.

Based on observations, the facility failed to properly maintain smoke barrier wall penetrations.

Findings Include:

On January 9, 2015 at 1:45 p.m., the maintenance person and surveyor found unsealed penetrations in the smoke barrier wall above the lay-in ceiling in three (3) of three (3) smoke barrier walls checked.

Based on observations, the facility failed to properly protect corridors from use areas as directed by NFPA 101 chapter 19.3.6.2.1.

Findings Include:

On January 9, 2015 between 1:00 p.m. and 2:00 p.m., the maintenance person and surveyor found numerous randomly located unsealed penetrations in the corridor walls above the lay-in ceiling.

19.3.6.2.1*
Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

Based on observations, the facility failed to properly protect hazardous areas.

Findings Include:

On January 9, 2015 at 2:15 p.m., the maintenance person and surveyor found the following hazardous areas to be lacking automatic door closers;

1) Lab
2) Clean utility
3) Medical records

Based on observations, the facility failed to properly maintain fire extinguishers as per
NFPA 10 4 - 4.3, and NFPA 10 4-4.4.2.

Findings Include:

On January 9, 2015 at 11:20 a.m., the maintenance person and surveyor found the K class fire extinguisher
located in the kitchen to be passed due for a six year inspection. The extinguisher was dated 2003.


NFPA 10 4-4.3
Six-Year Maintenance.
Every 6 years, stored-pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures. The removal of agent from halon agent fire extinguishers shall only be done using a listed halon closed recovery system. When the applicable maintenance procedures are performed during periodic recharging or hydrostatic testing, the 6-year requirement shall begin from that date.

4-4.4.2* Verification of Service (Maintenance or Recharging).
Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged (see 4-5.5) shall have a " Verification of Service " collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The " Verification of Service " collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch.
Exception No. 1: Fire extinguishers undergoing maintenance before January 1, 1999.
Exception No. 2: Cartridge/cylinder-operated fire extinguishers do not require a " Verification of Service " collar.

Based on observations, the facility failed to properly maintain smoke barrier wall penetrations.

Findings Include:

On January 9, 2015 at 1:45 p.m., the maintenance person and surveyor found unsealed penetrations in the smoke barrier wall above the lay-in ceiling in three (3) of three (3) smoke barrier walls checked.