HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the CEO, and Director of Physical Plant Services it was observed that the facility failed to provide fire rated sealant at wall penetrations in the rated walls at the following locations throughout the hospital facility:
1. CORRIDOR - At wall above the cross-corridor doors (doors located near, and north of the MEDICAID OFFICE).
A. Unsealed low-voltage cable penetration.
2. CORRIDOR - At wall above the cross-corridor doors (doors located near, and west of the MEDICAID OFFICE).
A. Unsealed penetration at bottom of structural joist.
3. CORRIDOR - At opposite side of wall above the cross-corridor doors (doors located near, and west of the MEDICAID OFFICE).
A. Unsealed penetration at top of rated partition. This structural penetration has gaps wide enougn at some points that it will require fire-safing material in addition to fire rated sealant.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the CEO, and Director of Physical Plant Services it was observed that the facility failed to provide a log indicating compliance with requirement for monthly testing by staff of the fire alarm system and its automatic signal response.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the CEO and the Director of Physical Plant Services the facility failed to provide a log showing the required yearly inspection of the sprinkler system.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the CEO, and Director of Physical Plant Services it was observed that the facility failed to provide a smoke detector within 5 feet of the door at each set of cross-corridor doors located in the rated walls separating the various smoke compartments of the hospital facility.

Based on observations made during the survey of the facility between the hours of 1:00 pm and 6:00 pm, while accompanied by the Administrator, Director of Nursing and Building Maintenance it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to provide compliance with the following:

1. There was no log indicating consistent, systematic compliance on Air filter changes for Air Handling Unit #3.

2. It was observed in the review of documentation that multiple fire door locations are routinely propped open violating the integrity of the rated partition assembly in which each of the door assemblies are located.