HospitalInspections.org

Based on documentation review, observation and interview, it was determined the facility failed to install and maintain the automatic sprinkler system in two instances, affecting the entire facility.

Findings include:

1. Document review on February 27, 2017, at 1:11 p.m., revealed a deficiency was recorded on four of four quarterly sprinkler inspection reports from an outside vendor due to the lack of a hydraulic nameplate on the automatic sprinkler system riser.

Interview with the Director of Nursing and Facility Staff on February 28, 2017 at 1:00 p.m., confirmed the hydraulic nameplate was missing.

2. Observation on February 28, 2017, at 9:38 a.m., revealed a quick response sprinkler head was mixed with standard response heads in the basement laundry room.

Interview with the Director of Nursing and Facility Staff on February 28, 2017 at 1:00 p.m., confirmed the sprinkler heads in the laundry room were mixed response types.

Based on observation and interview, it was determined the facility failed to maintain corridor walls in one instance on one of two floors.

Findings include:

1. Observation on February 28, 2017, at 10:34 a.m., revealed an unsealed penetration below the ceiling in the corridor wall, inside of Room 140, on the first floor.

Interview with the Director of Nursing and Facility Staff on February 28, 2017 at 1:00 p.m., confirmed the unsealed penetration.