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SHERIDAN MEMORIAL HOSPTIAL
Doors with Self-Closing Devices
Tag No.: K0223
Based on observation, the facility failed to ensure doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7.
This deficiency affects 1 out of 1 smoke compartment.
Findings include:
During an observation on 2/7/24 at 1:06 p.m., the PT Rehab pool door was inspected. The door was fitted with a self-closure and was held open by a rubber wedge.
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on observation, interview, and record review the facility failed to:
a) failed to ensure the gauges on the sprinkler standpipe were replaced or recalibrated every 5 years in accordance with NFPA 25, 2011 edition, section 6.3.4.1
b) failed to ensure sprinkler piping was fee from external loads in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2
c) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1 (3).
This deficiency affects all smoke compartments at the facility.
Findings include:
1. Review of the facility's records on 2/7/24 showed the facility's pressure gauges on the sprinkler standpipe had not been recalibrated since 2018.
During an interview on 2/7/24 at 12:58 p.m., staff member C stated the gauges should have been replaced in December of last year (2023).
2. During an observation on 2/7/24 at 12:47 p.m., the server room was inspected. There were cords hanging off the sprinkler piping, as well as a towel wrapped around the sprinkler piping.
3. During an observation on 2/7/24 at 12:55 p.m., the laundry water supply room was inspected. There was a ceiling tile missing. This could impede the sprinkler's distribution and performance if activated.
4. During an observation on 2/7/24 at 1:10 p.m., the hospital soiled linen room was inspected. There was a ceiling tile missing. This could impede the sprinkler's distribution and performance if activated.