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Tag No.: K0038
This tag not met as observed by this surveyor and a maintenance person. It was observed that outside of the Nuclear Medicine room signage on the ceiling was obscuring the exit sign for that corridor. No signage shall be placed in area that it may conceal or obscure an exit. NFPA 101, section 7.5.2.2, Exit access and exit doors shall be designed and arranged to be clearly recognizable. Hangings or draperies shall not be placed over exit doors or located to conceal or obscure any exit.
Tag No.: K0076
This tag not met as observed by this surveyor and a facility maintenance person. It was observed that in the compressed gas storage area in the facility gases were being stored to close to combustibles (less than 5 feet). There were over twenty nonflammable cylinders were being stored in the area. NFPA 99, section 9.4, Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) A minimum distance of 6.1 m (20 ft)
(2) A minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) An enclosed cabinet of noncombustible construction having a minimum fire protection rating of ½ hour
Tag No.: K0130
The following additional deficiencies were noted during this survey: 1) Improper use of extension cords in the facility gift shop. 2) Small hole in the fire wall located above the ceiling outside the cafeteria just above the bulliten board. 3) Escutcheons plate missing from the sprinkler head in Radiology room 2. 4) Emergency light required for the facility generator room. 5) Excessive about of combustible storage in the emergency generator room adding to the fire load of the area.