HospitalInspections.org

Based on observation and interview, the facility served by a complete automatic sprinkler system failed to ensure protection of hazardous enclosures in the corridors on three of three levels throughout the facility with fire rated doors and door frames in accordance with 8.4.1.3 to prevent fire and smoke from spreading to affect all staff, patients and visitors in the 35 bed Long Term Care Hospital. The facility census was 33 patients.

Findings included:

Observation on 11/02/11 at 8:50 AM through 11/04/11 at 10:00 AM showed paint obscured the fire rating labels on 10 of 10 corridor door frames to janitor's closets, equipment storage rooms, electrical and data closets, soiled utility rooms, a pair of fire doors dividing the smoke two compartments, and the exit egress doors at each end of the first floor corridor. Fire rating labels on eight of eight rated door frames on the second floor and nine of nine rated door frames on the third floor were obscured in like manner by paint that rendered the label unreadable.

During an interview on 11/02/11, at 11:20 PM, the Plant Operations Director said his maintenance worker is a retired painter and he would have him find the best product that removed the paint on the frames without damaging the lettering. He said he was aware that the rating labels on rated doors and door frames must be preserved to prevent voiding the factory-applied fire rating.