HospitalInspections.org

Based on observation and record review, it was determined the facility failed to ensure the sprinkler system was maintained (NFPA 25, Table 9-1 & 9-2.7).
The findings include:
1. Observation and interview on a follow up survey on 4/27/15 10:00 a.m. revealed the following sprinkler heads are covered with lint or corroded;

- 1 of 20 sprinkler heads above the 3 bay sink in dietary is corroded.

2. Observation with the Maintenance Director on a follow up survey on 4/27/15 at 10:15 AM confirmed standard response and quick response sprinkler heads mixed in the same compartment in the following location:
- Corridor outside the diagnostic care center.

These findings were verified and acknowledged by the Maintenance Supervisor's during the exit conference on 4/27/15.

Based on record review and interview, it was determined that the facility failed to maintain fire and smoke dampers in the building. (NFPA 96)


The findings include:

Interview with the maintenance director during a follow up survey on 4/27/15 at 10:00 AM revealed the following fire dampers and smoke dampers are not maintained;

1) Fire Dampers 1-FD-012, 1-FD-024 and P-FD-060 are not accessible.
2) Fire Damper P-FD-005 has a broken spring.
3) Smoke Dampers 1-SD-017 and 1-SD-018 are not accessible.
4) Smoke Damper 1-SD-014 has no air to the actuator.

This finding was verified by the maintenance director and acknowledged by the assistant administrator during the exit conference on 4/27/15.