HospitalInspections.org

Based on observations, the facility failed to select, installed, inspected, and maintained in portable fire extinguishers in accordance with NFPA 101 section 19.3.5.12 and NFPA 10, Standard for Portable Fire Extinguishers. The deficient practice affected the entire facility on the day of the survey.

Findings Include:

On 5/18/21 at 11:15AM, observation revealed 15 of 26 fire extinguishers in the facility were late and overdue for 6-year inspection. This deficiency finding was also noted in the contractor annual inspection report of the facility fire extinguishers.

The findings were acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 5/18/21.

Based on observations, the facility failed to properly protect corridor openings, in accordance with NFPA 101 section 19.3.6.4.1. The deficient practice affected the entire facility on the day of the survey.

Findings Include:

On 5/18/21 at 10:45AM, observation revealed air transfer grilles in the following corridor door openings of the facility:

1. Assistant Director of Nursing Office
2. Trapeze Room
3. File Storage Room

These corridor doors findings were incapable of resisting the passage of smoke throughout the facility.
The findings were acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 5/18/21.