HospitalInspections.org

Based upon observations there is are fire rated doors that are not self closing and latching to maintain the required fire resistance ratings of the assemblies.

Findings include

Between 1:30 PM and 2:30 PM on 6/17/19, it is observed that the fire rated door to hospital is not self-closing and latching and the door Coordinator that holds the active leave open until the inactive leave closes is not working properly.

Based upon observations therethere are doors that require excessive force to unlock the door, non approved door hardware that could affect the egress from spaces or the facility.

Findings include


Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that excessive force is required to open up exterior door by room 126 and the time delay initiation took three seconds instead of one second



Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that there is a throw bolt latch on the door between 128 and 127.


Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that bed stored in the corridor to the hospital is obstructing egress from the second floor.

Based upon observations there time delay locks the the door requires excessive force to unlock the door and restricts the full operation of the doors so occupants can egress the facility.

Findings include

Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that time delay lock by room 140 on the left side requires excessive force to initiate the irreversible countdown to unlock the lock.

Based upon observations there are areas that do not have the required emergency lighting.

Findings include

Between 9:30 AM and 3:00 PM on 6/13/19, during review of documentation it is observed that the facility does not have the required emergency lighting at exterior at the exit discharge doors.

Based upon review of documentation and observations the inspection report for suppression system notes that there is a deficiency with the suppression system.

Findings include

Between 9:30 AM and 3:00 PM on 6/13/19, it is observed that the battery for FM200 failed that is noted on suppression report dated 1-25-19.

Based upon observations hazardous areas are not maintained to provide required separation and or fire resistant ratings for the hazardous areas that could allow smoke and hot gasses to pass through the doors.

Findings include

Around 8:00 AM on 6/14/19, it is observed that joint at the top of the fire rated walls, around the penetrations of beams and electrical MC cable is not fire stopped with a listed product and listed fire stop design for the oxygen storage room.

Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that is penetrations in soiled utility room Biohazard sold utility room that is not fire stopped with a listed design and product.

Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that there are penetrations in fire rated soiled utility room wall on across from garden two that is not fire stopped with a listed design and product.

Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that Gametes fire rated wall in the second floor this is the bed storage room storage bio-med and the fire rated doors are not self closing and latching and the gaps are greater than 1/8 of an inch plus 1/16".

Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that the gap is greater than an eight of and inches plus or minus the 16th inch at fire rated doors on ground.

Based upon observations of the fire alarm system that there are areas where the required smoke detection devices are not installed according to NFPA 72.

Findings include

Around 8:16 AM on 6/14/19, it is observed that there is a fire alarm smoke detector that is too close to diffuser across from oxygen storage room.

Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that there is no sign on or near the door noting that the electrical room contains the main fire alarm control panel.

Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that ground floor smoke detector is too close to an air diffuser.

Based upon observations of the sprinkler system that the required maintenance of the system is not being maintained.


Findings include


Between 9:30 AM and 3:00 PM on 6/13/19, during review of documentation it is observed that Does seem to be that sprinkler reports do not contain all information and does not designate if annual, quarterly.


Between 9:30 AM and 3:00 PM on 6/13/19, during review of documentation it is observed that sprinkler reports notes that the sprinkler control valve was not tested due accessibility and shelf in the way.

Based upon review of documentation and observations of fire extinguisher training documentation is not available at time of survey.

Findings include

Between 9:30 AM and 5:15 PM on 6/13/19, during review of documentation it is observed that documentation for annual in service training of employees for fire extinguisher was not available at time of survey

Based upon observations of all corridor doors there are doors found that did not have positive latching that could allow smoke to pass through the doors.

Findings include


Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that corridor door by room 123 the door hardware sticks and sometimes don't latch


Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that a corridor door near 128 is not self-closing and latching.


Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that corridor door by room 134 is not self-closing and latching.


Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that corridor door and therapy area across from patient access is not latching.

Based upon observations the fire rated smoke barrier walls have penetrations, joints and openings that are not fire stopped and could allow smoke to pass from one side of the smoke barrier to the other side.

Findings include

Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that fire rated wall at the smoke barrier doors near managing manager therapy services office and the wall to the exterior is not constructed properly to maintain the one-hour fire rating. There are penetrations of a beam that is not fire stopped with a listed design and product, and the corners of the wall is not constructed according to the listed design.

Based upon observations of the electrical system, emergency lighting and exit signs that the required maintenance of the system is not being maintained.


Findings include

Between 3:00 PM and 3:15 PM on 6/17/19, it is observed that the clear working space in front of the electrical panel is not maintained clear of storage. NFPA 101 39.5, 9.1.2 NFPA 70


Between 3:00 PM and 3:15 PM on 6/17/19, during review of documentation and observations, the facility does not have the documentation for monthly and annual inspection and testing of battery powered emergency lighting and exit signs. NFPA 101 39.2.10, 7.10.9

Based upon interviews the facility does not have documentation that the fire dampers have been inspected and tested within the last four years and fire dampers are not installed according to manufactures installation instructions.

Findings include:

Between 9:30 AM and 3:00 PM on 6/13/19, during review of documentation it is observed that the fire smoke damper inspection report dated 6-13-13 was only for fire/smoke dampers and tested according to NFPA 72.. The facility did not have manual fire damper test and inspection report at time of survey.

Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that fire damper/smoke above the smoke barrier doors near managing manager therapy services office is not installed according to manufacturer's installation instructions.


Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that the fire dampers above the smoke barrier doors by room next 131 is not installed according to the manufacturers installation instructions.

Based upon observations and review of documentation that the did not have the risk assessment plan.

Findings include

Between 9:30 AM and 3:00 PM on 6/13/19, during review of documentation it is observed that Documentation for risk assessment was not available at time of survey.

Based upon observations the electrical systems and equipment is not being maintained.

Findings include

Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that there is a receptacle that is loose in patient room 124.


Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that face of outlet box is too far back from the face of the wall for light switch in materials management storage room on ground floor.

Based upon review of documentation, observations and interviews that there is not complete documentation of the testing and inspection of the power strips

Findings include

Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that Hospital grade power strip in OT is mounted to a wall and not mounted to a cart and there is no documentation for testing annually.

Based observations of locations the oxygen cylinders does not contain all the required parts installed on the tanks.

Findings include


Between 8:00 AM and 3:00 PM on 6/14/19, it is observed that two of the liquid oxygen tanks where the gauges have the plastic covers missing from them.

Based on inquiries and observations for the liquid oxygen transferring of cylinders the facility did not have a policy for the use and transferring of liquid oxygen..

Findings include



Between 8:00 AM and 3:00 PM on 6/14/19, a question is asked if there is a policy on the use of liquid oxygen and was not available at time of survey.