HospitalInspections.org

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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 05/04/2022, during the tour of the facility from 10:30 am to 3:30 pm, the facility failed to provide the monthly inspections for the kitchen hood's automatic fire-extinguishing system. The last documented monthly inspection was conducted on 02/2022.

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

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

2012 NFPA 101, 19.3.7.3, and 8.5.6.3

This deficiency affects 1of 5 smoke compartments.

Findings include:

On 05/04/2022, during a tour of the facility from 10:30 pm to 3:30 pm, the surveyor observed orange non-fire rated foam sealant used to seal penetrations above the ceiling in the smoke barrier on the 300 Hall.

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