HospitalInspections.org

Based on observation and interview it was determined that the facility failed to maintain the construction type of the building.

Findings include:

It was observed on 10/31/2012, at approximately 03:25 PM, that there is an unprotected penetration of the floor/ceiling assembly by a dryer vent above the ceiling in room 8A.

It was observed on 10/31/2012, at approximately 03:26 PM, that there are multiple unprotected penetrations of the floor/ceiling assembly by PVC pipe, above the ceiling in room 8A.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain smoke tight corridors.

Findings include:

It was observed on 10/31/2012, at approximately 02:21 PM, that there is a unprotected penetration of the corridor wall by ductwork at the of the 26E office area to the rear of 2 West.

The above was observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the fire resistance rating of smoke barriers.

Findings include:

It was observed on 10/31/2012, at approximately 02:02 PM, that there is an unprotected penetration in the smoke barrier wall above the ceiling at the pair of doors to 2 West.

It was observed on 10/31/2012, at approximately 02:08 PM, that there is an improperly protected penetration in the smoke barrier wall at the fire/smoke dampers, above the ceiling in 26A.

It was observed on 10/31/2012, at approximately 02:45 PM, that there is an unprotected penetration in the smoke barrier wall above the ceiling at the pair of doors to 2 West, near 26J.

It was observed on 10/31/2012, at approximately 03:01 PM, that there is an unprotected penetration in the smoke barrier wall above the ceiling at the of doors to 2C, first floor.

It was observed on 10/31/2012, at approximately 03:13 PM, that there is an unprotected penetration in the smoke barrier ceiling by electrical conduit the the main electrical room, 1st floor.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain smoke tight and self-closing doors in the smoke barrier.

Findings include:

It was observed on 10/31/2012, at approximately 02:45 PM, that the door closer has been removed from door 17, leading to the day room.

The above was observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to properly protect identified hazardous areas.

Findings include:

It was observed on 10/31/2012, at approximately 02:11 PM, that there is an unprotected penetration in the rated wall above the door near the ductwork in hazardous area Room 20A.

It was observed on 10/31/2012, at approximately 02:12 PM, that there is an unprotected penetration in the rated wall by electrical conduit above the ceiling in hazardous area Room 20A.

It was observed on 10/31/2012, at approximately 03:25 PM, that there is an unprotected penetration in the rated wall by electrical conduit above the ceiling in hazardous area Room 8A.

It was observed on 11/02/2012, at approximately 12:45 PM that Room 8G is used for storage and does not meet the construction requirements of a storage room.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain exits readily accessible.

Findings include:

It was observed on 11/02/2012, at approximately 12:54 PM, that there is not an all weather path to the public way from the ground floor exit discharge of the west stairway.

The above was observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the HVAC system.

Findings include:

It was noted during record review on 11/02/2012, at approximately 11:00 AM, that the facility could not provide documentation that the automatic shut down devices are tested annually as required by 1999 NFPA 90A, Section 4-4.1.

The above were observed and confirmed by Engineering Staff and the Safety Officer.

Based on observation and interview it was determined that the facility failed to maintain the building so that no highly flammable decorations or furnishings are used.

Findings include:

It was observed on 10/31/2012, at approximately 02:40 PM that a combustible straw scarecrow decoration on the corridor bulletin board in the facility was not flame retardant.

The above were observed and confirmed by Engineering Staff and the Safety Officer.