HospitalInspections.org

Based upon observations made in the presence of the facility manager on 11-08-2021, it was determined that the facility did not maintain portable fire extinguishers in accordance with NFPA 10 and NFPA 101 19.3.5.12.

This deficiency affected all fire extinguishers.

Findings include:

1-During the record review the facility failed to provide documentation of all of the monthly fire extinguisher heft tests were completed. Missing were June, July, August, September and October. Records shall be kept to demonstrate at least the last 12 monthly inspections have been performed in accordance with NFPA 10 7.2.4.6.

Based upon observations made in the presence of the facility managers on 11-08-2021, it was determined that the facility did not maintain the fire resistance rating in accordance with NFPA 101 19.3.7., 8.5.3

The deficiency affected 3 of several fire/smoke compartments.

Findings include:
1-During the tour of the facility it was observed that the Fire barrier wall in the server room had a 3 inch pipe passing thru the wall that was not sealed and not in accordance with NFPA 101 19.3.7.3, 8.5.
2- During the tour of the facility it was observed that the Fire barrier wall on the first floor in the med room had a 3 inch pipe passing thru the wall that was not sealed and not in accordance with NFPA 101 19.3.7.3, 8.5.
3-- During the tour of the facility it was observed that the Fire barrier wall in the mechanical room had (2) approx.2 inch penetrations and not in accordance with NFPA 101 19.3.7.3, 8.5.