HospitalInspections.org

The inspector observed, while accompanied by the Administrator during the hours of the inspection from 9:00 am to 12:15 pm on 4/20/2016 that there were the following issues. The double doors located near room #14 failed to close completely when released from the magnetic hold open.

Corridor doors must be 1 3/4 inch solid bonded wood core doors or they must have a 20 minute fire resistance rating. If the building is sprinklered the door must only resist the passage of smoke. There must be no impediment to closing the door, and latching devices must be provided which will keep the door tightly closed in the frame. LSC 12-3.6.3, 13-3.6.3

The inspector observed, while accompanied by the Administrator during the hours of the inspection from 9:00 am to 12:15 pm on 4/20/2016 that there were the following issues. The rated double doors near rooms #10, double doors near room #30, and the double doors near the entrance to the operating room were missing astragals.

Door openings in smoke barriers have at least a 20 minute fire protection rating or are at least 13/4 inch thick solid bonded core wood. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal sliding doors comply with 7.2.1.14. Swinging doors shall be arranged so that each door swings in an opposite direction. Doors shall be self-closing and rabbets, bevels or astragals are required at the meeting edges. Positive latching is not required. 18.3.7.5, 18.3.7.6, 18.3.7.8

The inspector observed, while accompanied by the Administrator during the hours of the inspection from 9:00 am to 12:15 pm on 4/20/2016 that there were the following issues. The fire alarm breaker within the panel box was not marked in red.

''The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as ''FIRE ALARM CIRCUIT CONTROL'' '' - NFPA 72, 2002: 4.4.1.4.2.2.

The inspector observed, while accompanied by the Administrator during the hours of the inspection from 9:00 am to 12:15 pm on 4/20/2016 that there were the following issues.
Based on observation the facility failed to keep storage of materials in the pharmacy the minimum distance below the sprinkler heads.

''A minimum clearance of 18 inches shall be maintained between the top of storage and sprinkler deflectors'' - NFPA 13, 2002: 8.5.6.1.

The inspector observed, while accompanied by the Administrator during the hours of the inspection from 9:00 am to 12:15 pm on 4/20/2016 that there were the following issues. Based on observation the facility failed to provide a type K fire extinguisher in the kitchen.

Portable fire extinguishers are provided and maintained per NFPA 10. LSC 12-3.5.5, 13-3.5.5

The inspector observed, while accompanied by the Administrator during the hours of the inspection from 9:00 am to 12:15 pm on 4/20/2016 that there were the following issues. The double doors located near room #14 failed to close completely when released from the magnetic hold open.

Corridor doors must be 1 3/4 inch solid bonded wood core doors or they must have a 20 minute fire resistance rating. If the building is sprinklered the door must only resist the passage of smoke. There must be no impediment to closing the door, and latching devices must be provided which will keep the door tightly closed in the frame. LSC 12-3.6.3, 13-3.6.3

The inspector observed, while accompanied by the Administrator during the hours of the inspection from 9:00 am to 12:15 pm on 4/20/2016 that there were the following issues. The rated double doors near rooms #10, double doors near room #30, and the double doors near the entrance to the operating room were missing astragals.

Door openings in smoke barriers have at least a 20 minute fire protection rating or are at least 13/4 inch thick solid bonded core wood. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal sliding doors comply with 7.2.1.14. Swinging doors shall be arranged so that each door swings in an opposite direction. Doors shall be self-closing and rabbets, bevels or astragals are required at the meeting edges. Positive latching is not required. 18.3.7.5, 18.3.7.6, 18.3.7.8

The inspector observed, while accompanied by the Administrator during the hours of the inspection from 9:00 am to 12:15 pm on 4/20/2016 that there were the following issues. The fire alarm breaker within the panel box was not marked in red.

''The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as ''FIRE ALARM CIRCUIT CONTROL'' '' - NFPA 72, 2002: 4.4.1.4.2.2.

The inspector observed, while accompanied by the Administrator during the hours of the inspection from 9:00 am to 12:15 pm on 4/20/2016 that there were the following issues.
Based on observation the facility failed to keep storage of materials in the pharmacy the minimum distance below the sprinkler heads.

''A minimum clearance of 18 inches shall be maintained between the top of storage and sprinkler deflectors'' - NFPA 13, 2002: 8.5.6.1.

The inspector observed, while accompanied by the Administrator during the hours of the inspection from 9:00 am to 12:15 pm on 4/20/2016 that there were the following issues. Based on observation the facility failed to provide a type K fire extinguisher in the kitchen.

Portable fire extinguishers are provided and maintained per NFPA 10. LSC 12-3.5.5, 13-3.5.5