HospitalInspections.org

Based on observation the facility failed to provide acceptable smoke barrier separations.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that there were multiple locations that require patching holes in the smoke barrier partitions. The were above the cross corridor doors at: 1) the main N/S corridor near the nurse station, 2) the cross corridor door between the nurse station and the northeast wing, and 3) above the north exit to the clinic.

Based on observation the facility failed to provide an acceptable enclosure for hazardous storage areas.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that there were storage and other hazardous areas that did not have an acceptable enclosure. They were: 1) there was a basement paint storage room with space heaters that had a door without a closer, 2) there was a basement water heater room that did not have a closer, 3) there was a basement bio hazard room that did not have an intact solid core door or a closer, 4) there was a new storage room by the E.R. entry that will require 45 minute doors and closers, 5) there was a film storage room that requires a solid core door and a closer, 6) there was a medical records room open to a egress corridor that requires a closer, 7) there was a storage room at the end of the southwest wing that had an incomplete wall, a pocket door and no closer, the wall shall be smoke tight relative to the corridor and the door must be a solid core swinging door with a closer, and 8) there was a small storage closet at the end of the north corridor of the administrative wing that requires a closer.

Based on observation the facility failed to provide an acceptable exit on the southeast wing of the building.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that the egress pathway went through a storage room on the north side of the corridor. Storage rooms are hazardous areas and exiting through a hazardous area is not permitted.

Based on observation the facility failed to provide an acceptable source of illumination at an exit.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that there was only one source of illumination at the northern exit adjacent to room 227.

Based on observation the facility failed to provide an acceptable power reference for the main fire alarm control panel.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that breaker #6 in panel CB shall be required to be colored red.

Based on observation the facility failed to keep storage of materials the correct distance below the sprinkler heads.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that there were items stored in the lab that were above the 18 inch plane that starts from the bottom of the sprinkler head and goes downward.

Based on observation the facility failed to provide acceptable flame spread data for a bath room curtain.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that there was a curtain in a bathroom that did not have proper documentation, i.e. passing NFPA 701.

Based on observation the facility failed to provide acceptable labeling of the medical gas lines.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that there was locations above the ceiling in the corridors were the medical gas lines were not labeled. Pipe labels shall be located as follows: (1) at intervals of not more than 20 ft., (2) at least once in or above every room, (3) on both sides of walls or partitions penetrated by the piping, and (4) at least once in every story height traversed by risers - NFPA 99, 2002: 5.1.11.1.4.

Based on observation the facility failed to provide an acceptable electrical system in accordance with NFPA 70.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that there was not a current directory in panel ES.

Based on observation the facility failed to provide acceptable smoke barrier separations.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that there were multiple locations that require patching holes in the smoke barrier partitions. The were above the cross corridor doors at: 1) the main N/S corridor near the nurse station, 2) the cross corridor door between the nurse station and the northeast wing, and 3) above the north exit to the clinic.

Based on observation the facility failed to provide an acceptable enclosure for hazardous storage areas.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that there were storage and other hazardous areas that did not have an acceptable enclosure. They were: 1) there was a basement paint storage room with space heaters that had a door without a closer, 2) there was a basement water heater room that did not have a closer, 3) there was a basement bio hazard room that did not have an intact solid core door or a closer, 4) there was a new storage room by the E.R. entry that will require 45 minute doors and closers, 5) there was a film storage room that requires a solid core door and a closer, 6) there was a medical records room open to a egress corridor that requires a closer, 7) there was a storage room at the end of the southwest wing that had an incomplete wall, a pocket door and no closer, the wall shall be smoke tight relative to the corridor and the door must be a solid core swinging door with a closer, and 8) there was a small storage closet at the end of the north corridor of the administrative wing that requires a closer.

Based on observation the facility failed to provide an acceptable exit on the southeast wing of the building.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that the egress pathway went through a storage room on the north side of the corridor. Storage rooms are hazardous areas and exiting through a hazardous area is not permitted.

Based on observation the facility failed to provide an acceptable source of illumination at an exit.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that there was only one source of illumination at the northern exit adjacent to room 227.

Based on observation the facility failed to provide an acceptable power reference for the main fire alarm control panel.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that breaker #6 in panel CB shall be required to be colored red.

Based on observation the facility failed to keep storage of materials the correct distance below the sprinkler heads.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that there were items stored in the lab that were above the 18 inch plane that starts from the bottom of the sprinkler head and goes downward.

Based on observation the facility failed to provide acceptable flame spread data for a bath room curtain.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that there was a curtain in a bathroom that did not have proper documentation, i.e. passing NFPA 701.

Based on observation the facility failed to provide acceptable labeling of the medical gas lines.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that there was locations above the ceiling in the corridors were the medical gas lines were not labeled. Pipe labels shall be located as follows: (1) at intervals of not more than 20 ft., (2) at least once in or above every room, (3) on both sides of walls or partitions penetrated by the piping, and (4) at least once in every story height traversed by risers - NFPA 99, 2002: 5.1.11.1.4.

Based on observation the facility failed to provide an acceptable electrical system in accordance with NFPA 70.

The inspector observed while accompanied by the Plant Operation and Safety Manager during the hours of the inspection from 8:00 am to 12:00 pm that there was not a current directory in panel ES.