HospitalInspections.org

Based on observations and staff interview, the facility failed to maintain all 2 hour rated walls with doors at least 1-1/2 hour fire rated in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.1.3.5 and 8.2.1.3. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observations and staff interview on 6/2/21, between 9:30 a.m. and 1:30 p.m., revealed the following deficiencies:

1. The wall separating the Hospital from the Ambulance Garage was verified to be a 2 hour rated wall by Maintenance Staff. There is no available information indicating that the folding door installed in this 2 hour rated wall is rated at least 1-1/2 hour as required. The original doors in the 2 hour wall have been removed and replaced with the folding door.
2. There was a penetration, (approximately 1 inch), around two blue communication lines extending through the Plaza 2 hour rated wall.

Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the fire alarm system is out of service for more than four hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.6.1.6. and NFPA 25, 2011 Edition. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Record review and staff interview on 6/2/21 at 11:06 a.m., revealed the facility's sprinkler system outage policy did not contain language to specifically address the following conditions as required: System leakage. Interruption of water supply. Ruptured piping. Equipment failure. Maintenance Staff verified record review during the survey process.

Based on observation and staff interview, this facility is not maintaining the sprinkler system in accordance with National Fire Protection Association, NFPA 25, 2011 edition and National Fire Protection Association, NFPA 13, 2010 edition. The facility has a capacity of 25 with a census of 6 patients.

Findings include:

Observation and staff interview on 6/2/21 at 12:02 p.m., revealed a missing escutcheon around a sprinkler head installed in the ceiling tile grid in the Surgery Central Storage Room. Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide emergency plans and procedures as required by National Fire Protection Association, NFPA 101, 2012 Edition, 19.7.2.2. The facility has a capacity of 25 with a census of 6 patients.

Findings include:


Record review and staff interview on 6/2/21 at 10:58 a.m., revealed the facility's fire emergency plan and procedures policy did not contain language on the use of the Kitchen Hood and Duct Extinguishment System as required. Maintenance Staff verified record review during the survey process.