HospitalInspections.org

Based on observations the facility failed to provide the required 2 hour fire resistance rating for separation walls between non-conforming structures.

While inspecting facility construction on 01/12/10 the surveyor observed the treatment wing and the patient wing were two different construction types. The surveyor observed the two hour wall separating the (2) wings with unsealed penetrations, unfinished construction, and an obstruction to prohibit the door from closing.

Based on observations the facility failed to provide the required fire rated construction and or a sprinkler system for structural elements.

While inspecting facility construction on 01/12/10 the surveyor observed the treatment wing had unprotected wood structural elements throughout the facility. The original building was constructed with a plaster ceiling protecting the wood structure. This plaster ceiling was removed in several locations and found with unsealed penetrations throughout.

This deficient practice has the potential of affecting 4 of 4 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required ? hour fire resistance rating for corridor walls in a non-sprinkled facility.

While inspecting corridor walls on 01/12/10 the surveyor observed the corridor walls in the treatment wing (X-ray corridor) with unsealed penetrations throughout. The surveyor also observed (2) sets of windows in the corridor located at the front office with unrated glass.

This deficient practice has the potential of affecting 2 of 4 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required ? hour fire resistance rating for smoke barrier walls.

While inspecting smoke barrier walls on 01/12/10 the surveyor observed the smoke barrier wall separating the patient sleeping wing with unsealed penetrations and unfinished construction. The surveyor also observed the smoke barrier wall separating the treatment wing (X-ray corridor) with penetrations throughout.

This deficient practice has the potential of affecting 4 of 4 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required 2 master alarm panels for there bulk oxygen system.

While inspecting the bulk oxygen system on 01/12/10 the surveyor observed the facility only had 1 master alarm panel for the bulk oxygen system.

This deficient practice has the potential of affecting 4 of 4 smoke compartments. The administrator and the maintenance director were notified during the survey as well as the exit conference.