HospitalInspections.org

Based on observation, interview and record review, the facility failed to maintain and test a complete automatic sprinkler system. Seven out of seven smoke compartments in building could be affected by the deficient practice and potentially affected all visitors, staff, and one patient. The facility has 25 certified beds and at the time of the survey the census was 1.

Findings include:

During the record review of the facility's fire safety components, it was confirmed by testing dates and interview with the facility maintenance personnel, that the facility sprinkler system was not being inspected for the 5 year internal inspection as required. The record review and interview was conducted on 12/7/10 and 3/10/11, revealed that the sprinkler system had not had a 5 year internal inspection conducted. The facility was unable to produce documentation that the test had been conducted.
Maintenance Staff A confirmed observations during the survey process.