HospitalInspections.org

Based on observation, and interview, ceiling tiles were not in place. This deficient practice affects the construction type of the building and could affect all occupants including residents, staff and visitors.

Findings include:

During the facility tour on 7-12-10 between 12:30-3:00PM, it was observed that the ceiling tiles were not in the grid work in several locations. The tiles are required to be in place to protect the construction framing members above, and to serve as heat collectors for the complete automatic fire sprinkler system as required by LSC(00 section 19.3.5.1.

This deficient practice was confirmed by the Director of Maintenance (PC) at the time of exit.

Based on observation the doors on the lower level locker room did not have latches on them, as required by the LSC(00) Section 19. 3.6.3. This deficient practice could affect all residents, staff, and visitors, in the event of a fire.

Findings include:

During the facility tour on 7-21-10 at 1:00PM it was observed that the doors (2) into the lower level locker room did not have latches on them.


This deficient practice was confirmed by the facility Director of Maintenance (PC) at the time of discovery.

At the time of inspection a fire drill was conducted in the radiology area. Staff did not respond appropriately as outlined in LSC(00) sections 19.7.2.1 & 19.7.2.3.

Findings include:

During the facility tour on 7-21-10, at 2:45PM a fire drill was conducted in the radiology area. Based on observations, the staff in the area were not properly trained in fire emergency procedures. Staff were not familiar with the actions required using R.A.C.E. The alarm was not activated, and the over head page was not audible in all areas of the facility. The facility is in the process of implementing a "new" fire drill procedure at this time.

This deficient practice was confirmed by the facility Director of Maintenance (PC) and the facility Safety Office (AC) at the time of exit.

Based on observation, the facility's fire alarm system is not installed in conformance with NFPA 72. This deficient practice could affect all occupants including all patients, staff and visitors.

Findings include:

During the facility tour between on 7-21-10 between 12:30-3:00PM it was observed that several fire alarm connected smoke detectors in the 2004 building are located within 3 feet of HVAC deflectors.


This deficient practice was confirmed by the Maintenance Supervisor (PC) at the time of exit.

Based on observation the control valves on the complete automatic fire sprinkler system are no secured in the open position as required by MSFC(06) section 903.4.4 This deficient practice could affect all occupants including residents, staff and visitors.

Findings include:

Based on observation during the facility tour on 7-21-10 between 12:30-3:00PM it was observed that the valves controlling the complete automatic fire sprinkler system are not secured in the open position. The Director of Facility Maintenance stated that "they were all secured and the fire sprinkler inspector must not have put them back at the time of the lat annual inspection" .

This deficient practice was confirmed by the Director of Maintenance (PC) at the time of exit.

Based on observation, and interview, ceiling tiles were not in place. This deficient practice affects the construction type of the building and could affect all occupants including residents, staff and visitors.

Findings include:

During the facility tour on 7-12-10 between 12:30-3:00PM, it was observed that the ceiling tiles were not in the grid work in several locations. The tiles are required to be in place to protect the construction framing members above, and to serve as heat collectors for the complete automatic fire sprinkler system as required by LSC(00 section 19.3.5.1.

This deficient practice was confirmed by the Director of Maintenance (PC) at the time of exit.

Based on observation the doors on the lower level locker room did not have latches on them, as required by the LSC(00) Section 19. 3.6.3. This deficient practice could affect all residents, staff, and visitors, in the event of a fire.

Findings include:

During the facility tour on 7-21-10 at 1:00PM it was observed that the doors (2) into the lower level locker room did not have latches on them.


This deficient practice was confirmed by the facility Director of Maintenance (PC) at the time of discovery.

At the time of inspection a fire drill was conducted in the radiology area. Staff did not respond appropriately as outlined in LSC(00) sections 19.7.2.1 & 19.7.2.3.

Findings include:

During the facility tour on 7-21-10, at 2:45PM a fire drill was conducted in the radiology area. Based on observations, the staff in the area were not properly trained in fire emergency procedures. Staff were not familiar with the actions required using R.A.C.E. The alarm was not activated, and the over head page was not audible in all areas of the facility. The facility is in the process of implementing a "new" fire drill procedure at this time.

This deficient practice was confirmed by the facility Director of Maintenance (PC) and the facility Safety Office (AC) at the time of exit.

Based on observation, the facility's fire alarm system is not installed in conformance with NFPA 72. This deficient practice could affect all occupants including all patients, staff and visitors.

Findings include:

During the facility tour between on 7-21-10 between 12:30-3:00PM it was observed that several fire alarm connected smoke detectors in the 2004 building are located within 3 feet of HVAC deflectors.


This deficient practice was confirmed by the Maintenance Supervisor (PC) at the time of exit.

Based on observation the control valves on the complete automatic fire sprinkler system are no secured in the open position as required by MSFC(06) section 903.4.4 This deficient practice could affect all occupants including residents, staff and visitors.

Findings include:

Based on observation during the facility tour on 7-21-10 between 12:30-3:00PM it was observed that the valves controlling the complete automatic fire sprinkler system are not secured in the open position. The Director of Facility Maintenance stated that "they were all secured and the fire sprinkler inspector must not have put them back at the time of the lat annual inspection" .

This deficient practice was confirmed by the Director of Maintenance (PC) at the time of exit.