HospitalInspections.org

While on tour of the facility with the Maintenance Staff E between August 6th, 2012 and August 7th, 2012, it was observed that this facility did not properly enclose hazardous areas with walls that were properly rated and sealed to the minimum standards for these rooms. This deficiency had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
Item #1: It was observed at 1:12pm on Monday August 6th with Staff E that a former conference room was now being used for a large amount of storage of combustibles and the room was greater than 100 square feet. The door was not labeled at 45 minutes, no door closer was present, and none of the perimeter walls were sealed on both sides at all penetrations to a one-hour rating. The function of this room changed in the last year and must meet new standards for a hazardous area. [First level /I-2 occupancy]
Item #11: It was observed at 7:33am on Tuesday August 7th with Staff E that none of the walls around Soiled Utility #223 were taped and mudded and some penetrations were not fire caulked to a one-hour rating. [Second level/I-2 occupancy]

While on tour of the facility with the Maintenance Staff E between August 6th, 2012 and August 7th, 2012, it was observed that this facility did not provide a sprinkler system that complied with code minimum standards as evidenced by the following item. This deficiency had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Finding includes:
Item #1. It was observed and noted in an interview with Staff E at 10:08am on Monday August 6th that no sprinkler head was installed within two of the three elevator equipment rooms. No alternate means of fire protection was found within either of these two rooms. The facility is not considered a 'completely protected' building. [Lower Level /I-2 occupancy]