HospitalInspections.org

Based on observation and staff interview, the facility consists of Type II, Protected Construction and is equipped with a complete sprinkler system. The facility failed to ensure that all holes and penetrations are properly sealed with fire rated construction or fire rated material. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observation and staff interview on 5/2/16 at 12:56 p.m., revealed a penetration, (approximately 1/4 inch), around a conduit extending through the ceiling of the Housekeeping Room by the Surgery Department Main Entrance. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, this facility is not assuring that all smoke barriers are free of gaps and penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association, 2000 Life Safety Code, existing edition, 19.3.7.3. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 5/2/16, between 10:00 a.m. and 1:30 p.m., revealed the following deficiencies:

1. There was a gap, (approximately 1/4 inch), on the east side of the smoke barrier wall separating the Clinic from Physical Therapy.
2. There was a penetration, (approximately 3/16 inch), around conduit and cable extending through the smoke barrier wall by the Laboratory Manager Office.
3. There was a penetration, (approximately 1/2 inch), around a cable extending through the smoke barrier wall by the Surgery Department Main Entrance.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility is not properly separating hazardous areas from other compartments by ensuring all holes and penetrations are properly sealed with fire rated construction or fire rated material. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 5/2/16 at 11:41 a.m., revealed 6 penetrations, (all approximately 1/4 inch), around 6 conduit extending through the ceiling of the Kitchen, above the Ansul Control Box. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, this facility is not maintaining the sprinkler system in accordance with National Fire Protection Association, NFPA 25, 1998 edition and National Fire Protection Association, NFPA 13. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 5/2/16, between 10:00 a.m. and 1:30 p.m., revealed the following deficiencies:

1. There was an escutcheon around a sprinkler head in the Laundry Room that was not flush with the ceiling.
2. There was a missing escutcheon for a sprinkler head located in the Housekeeping Room by the Surgery Department Main Entrance.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to maintain the building's electrical system in accordance with National Fire Protection Association, NFPA 70, 1999 Edition. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 5/2/16, between 10:00 a.m. and 1:30 p.m., revealed the following deficiencies:

1. Circuit breakers # 7, 8, 9 and 11 located in Electrical Panel E in the Generator Room were in the on position and were not labeled.
2. There was an electrical outlet in the basement corridor by Purchasing that was not flush with the wall, leaving an open gap which exposed electrical components.

Maintenance Staff A verified observations during the survey process.

Based on observation and staff interview, the facility consists of Type II, Protected Construction and is equipped with a complete sprinkler system. The facility failed to ensure that all holes and penetrations are properly sealed with fire rated construction or fire rated material. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observation and staff interview on 5/2/16 at 12:56 p.m., revealed a penetration, (approximately 1/4 inch), around a conduit extending through the ceiling of the Housekeeping Room by the Surgery Department Main Entrance. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, this facility is not assuring that all smoke barriers are free of gaps and penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association, 2000 Life Safety Code, existing edition, 19.3.7.3. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 5/2/16, between 10:00 a.m. and 1:30 p.m., revealed the following deficiencies:

1. There was a gap, (approximately 1/4 inch), on the east side of the smoke barrier wall separating the Clinic from Physical Therapy.
2. There was a penetration, (approximately 3/16 inch), around conduit and cable extending through the smoke barrier wall by the Laboratory Manager Office.
3. There was a penetration, (approximately 1/2 inch), around a cable extending through the smoke barrier wall by the Surgery Department Main Entrance.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility is not properly separating hazardous areas from other compartments by ensuring all holes and penetrations are properly sealed with fire rated construction or fire rated material. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 5/2/16 at 11:41 a.m., revealed 6 penetrations, (all approximately 1/4 inch), around 6 conduit extending through the ceiling of the Kitchen, above the Ansul Control Box. Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, this facility is not maintaining the sprinkler system in accordance with National Fire Protection Association, NFPA 25, 1998 edition and National Fire Protection Association, NFPA 13. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 5/2/16, between 10:00 a.m. and 1:30 p.m., revealed the following deficiencies:

1. There was an escutcheon around a sprinkler head in the Laundry Room that was not flush with the ceiling.
2. There was a missing escutcheon for a sprinkler head located in the Housekeeping Room by the Surgery Department Main Entrance.

Maintenance Staff A verified observations during the survey process.

Based on observations and staff interview, the facility failed to maintain the building's electrical system in accordance with National Fire Protection Association, NFPA 70, 1999 Edition. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 5/2/16, between 10:00 a.m. and 1:30 p.m., revealed the following deficiencies:

1. Circuit breakers # 7, 8, 9 and 11 located in Electrical Panel E in the Generator Room were in the on position and were not labeled.
2. There was an electrical outlet in the basement corridor by Purchasing that was not flush with the wall, leaving an open gap which exposed electrical components.

Maintenance Staff A verified observations during the survey process.