HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Interim CEO, CFO, Risk Manager and Maintenance Director it was observed that the facility failed to provide the required rating at the portion of the rated wall above the cross-corridor door opening located near the CHAPEL. This wall is part of the 1 hour fire/smoke rated SMOKE COMPARTMENT partition. There were multiple unsealed penetrations.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Interim CEO, CFO, Risk Manager and Maintenance Director it was observed that the facility failed to provide the required rating for the multiple 1 hour fire-rated walls built around the very large (storage type) room located outside of, but near the KITCHEN area. There were multiple unsealed penetrations all along these walls. Room name is unknown (see note below for description of room and room location).
ROOM LOCATION NOTE: In this very large room there is a 2 hour fire-rated wall which is the longest wall of the room. It separates this part of the HOSPITAL occupancy from the NON-HOSPITAL occupancy portion of the building. The NON-HOSPITAL portion of the building was labeled "WTLR".






This wall is part of the 1 hour fire/smoke rated SMOKE COMPARTMENT partition.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Interim CEO, CFO, Risk Manager, and Maintenance Director it was observed that the facility failed to provide a log indicating compliance with requirement for monthly testing by staff of the fire alarm system and its automatic signal response.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Interim CEO, CFO, Risk Manager, and Maintenance Director it was observed that while it appears the facility had accomplished some yearly inspections required for all fire extinguishers, the facility failed to provide a comprehensive log indicating consistant and routine compliance of such.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Interim CEO, CFO, Risk Manager and Maintenance Director it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to provide logs indicating consistent, systematic compliance on the following issues and items:

1. Air filter change log (log was incomplete and inconclusive).
2. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually

Additionally, the facility failed regarding the following:
3. In the KITCHEN's DRY FOOD STORAGE ROOM the required 18 inch clear zone below sprinkler heads was not provided.
4. In the KITCHEN's HOT FOOD PREP area the cooking equipment below the hood did not appear to have an emergency shut-off for the fuel source.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Interim CEO, CFO, Risk Manager, and Maintenance Director it was observed that the facility failed to provide an Emergency Generator log indicating consistent, systematic compliance on the following issues and items:

1. Weekly inspections.
2. Monthly load tests.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Interim CEO, CFO, Risk Manager and Maintenance Director it was observed that the facility failed to provide the required rating at the portion of the rated wall above the cross-corridor door opening located near the CHAPEL. This wall is part of the 1 hour fire/smoke rated SMOKE COMPARTMENT partition. There were multiple unsealed penetrations.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Interim CEO, CFO, Risk Manager and Maintenance Director it was observed that the facility failed to provide the required rating for the multiple 1 hour fire-rated walls built around the very large (storage type) room located outside of, but near the KITCHEN area. There were multiple unsealed penetrations all along these walls. Room name is unknown (see note below for description of room and room location).
ROOM LOCATION NOTE: In this very large room there is a 2 hour fire-rated wall which is the longest wall of the room. It separates this part of the HOSPITAL occupancy from the NON-HOSPITAL occupancy portion of the building. The NON-HOSPITAL portion of the building was labeled "WTLR".






This wall is part of the 1 hour fire/smoke rated SMOKE COMPARTMENT partition.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Interim CEO, CFO, Risk Manager, and Maintenance Director it was observed that the facility failed to provide a log indicating compliance with requirement for monthly testing by staff of the fire alarm system and its automatic signal response.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Interim CEO, CFO, Risk Manager, and Maintenance Director it was observed that while it appears the facility had accomplished some yearly inspections required for all fire extinguishers, the facility failed to provide a comprehensive log indicating consistant and routine compliance of such.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Interim CEO, CFO, Risk Manager and Maintenance Director it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to provide logs indicating consistent, systematic compliance on the following issues and items:

1. Air filter change log (log was incomplete and inconclusive).
2. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually

Additionally, the facility failed regarding the following:
3. In the KITCHEN's DRY FOOD STORAGE ROOM the required 18 inch clear zone below sprinkler heads was not provided.
4. In the KITCHEN's HOT FOOD PREP area the cooking equipment below the hood did not appear to have an emergency shut-off for the fuel source.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Interim CEO, CFO, Risk Manager, and Maintenance Director it was observed that the facility failed to provide an Emergency Generator log indicating consistent, systematic compliance on the following issues and items:

1. Weekly inspections.
2. Monthly load tests.