HospitalInspections.org

Based on observations and testing of corridor doors, it was determined that three corridor doors did not comply with NFPA 101 "The Life Safety Code" 2000 Edition Section 19.3.6.1. This deficient practice could allow the products of combustion to spread beyond the room of fire origin and negatively impact all 25 patients, the staff and any visitors of this facility.

Findings include:
During the facility tour on January 17, 2014, between 10:00 am and 12:30 pm, observations and testing of at least 50 corridor doors, by surveyor 03006, revealed that:
1) The double leaf corridor doors into the Imaging suite did not latch,
2) The locker room corridor into this same corridor was not positively latching, and
3) The conference room corridor doors did not latch properly.

These deficient practices were confirmed by the Director of Maintenance and the Voice President of Finance at the time of the inspection and during the exit conference.

Based on observations and an interview with staff it was determined that the automatic fire sprinkler system has not been installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems and NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.5. This deficient practice could allow a fire to progress throughout the building and negatively effect all 25 patients, the staff and any guests of the facility.

Findings include:
During the facility tour on January 17, 2014, between 10:00 am and 12:30 pm, observations and an interview with the Director of Maintenance and the Vice President Finance, by surveyor 03006, revealed that:

1) Most of the suspended ceiling in the server room is missing and the sprinkler head is
mounted on that ceiling plan, and

2) The IT data closet on 1st floor does not have a sprinkler head in it.

These deficient practices were confirmed by the Director of Maintenance and the Voice President of Finance at the time of the inspection and during the exit conference.

Based on observations and testing of corridor doors, it was determined that three corridor doors did not comply with NFPA 101 "The Life Safety Code" 2000 Edition Section 19.3.6.1. This deficient practice could allow the products of combustion to spread beyond the room of fire origin and negatively impact all 25 patients, the staff and any visitors of this facility.

Findings include:
During the facility tour on January 17, 2014, between 10:00 am and 12:30 pm, observations and testing of at least 50 corridor doors, by surveyor 03006, revealed that:
1) The double leaf corridor doors into the Imaging suite did not latch,
2) The locker room corridor into this same corridor was not positively latching, and
3) The conference room corridor doors did not latch properly.

These deficient practices were confirmed by the Director of Maintenance and the Voice President of Finance at the time of the inspection and during the exit conference.

Based on observations and an interview with staff it was determined that the automatic fire sprinkler system has not been installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems and NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.5. This deficient practice could allow a fire to progress throughout the building and negatively effect all 25 patients, the staff and any guests of the facility.

Findings include:
During the facility tour on January 17, 2014, between 10:00 am and 12:30 pm, observations and an interview with the Director of Maintenance and the Vice President Finance, by surveyor 03006, revealed that:

1) Most of the suspended ceiling in the server room is missing and the sprinkler head is
mounted on that ceiling plan, and

2) The IT data closet on 1st floor does not have a sprinkler head in it.

These deficient practices were confirmed by the Director of Maintenance and the Voice President of Finance at the time of the inspection and during the exit conference.