HospitalInspections.org

.

Based on observation, the facility failed to maintain a horizontal exit (4 hour fire barrier) per the requirements of:

2012 NFPA 101, 19.2.2.5, 7.2.4.3.1, and 8.3.5.1

This deficiency affects 2 of 5 smoke compartments.

Findings include:

On 11/30/2021, during a tour of the facility from 9:45 am to 3:00 pm, the surveyor observed an unsealed opening of a 4" conduit with multiple cables in the horizontal exit (4 hour fire barrier) above the ceiling over the fire doors on the East Wing at the East Wing Lobby.

A member of the maintenance staff was present when this deficiency was identified.
.

.

Based on review of documentation, the facility failed to maintain the kitchen hood's automatic fire-extinguishing system per the requirements of:

2012 NFPA 101, 19.3.2.5.1, and 9.2.3
2011 NFPA 96, 10.2.6 (4)
2009 NFPA 17A, 7.2.1, and 7.2.2

This deficiency affects 1 of 5 smoke compartments.

Findings include:

On 12/01/2021, during the review of documentation from 8:30 am to 11:30 am, the facility failed to provide the monthly inspections for the kitchen hood's automatic fire-extinguishing system. No documention of monthly inspections were provided.

A member of maintenance staff was present when this deficiency was identified.

.

.

Based on observation, the facility failed to maintain a corridor door per the requirements of:

2012 NFPA 101, 19.3.6.3.2
S&C-07-18

This deficiency affects 1 of 5 smoke compartments.

Findings include:

On 11/30/2021, during a tour of the facility from 9:45 am to 3:00 pm, the surveyor observed the East Wing Dictation room had a 5/8" gap between the door and door frame when the door was closed and latched.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation, the facility failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, and 8.5.6.3

This deficiency affects 2 of 5 smoke compartments.

Findings include:

On 12/01/2021, during a tour of the facility from 8:30 am to 11:30 am, the surveyor observed a 3/4" unsealed conduit with multiple black and white cables above the ceiling of the smoke barrier between the Front Nurses' Station Rest Room and the Chaple.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation, the facility failed to prohibit a portable space heating device per the requirements of:

2012 NFPA 101, 19.7.8

This deficiency affects 1 of 5 smoke compartments.

Findings include:

On 11/30/2021, during a tour of the facility from 9:45 am to 3:00 pm, the surveyor observed a portable space heating device under the wood desk in the Chief Financial Officers' Office. The facility was unable to provide documentation that the heating element did not exceed 212 degrees.

A member of the maintenance staff was present when this deficiency was identified.