HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 3:00 pm and 6:00 pm, while accompanied by the Acting Administrator, System Manager Plant Ops, System Manager Security & EOC, and BioMed Director it was observed that the facility failed to maintain the required 1 hour fire-rating for the south wall of the SOILED UTILITY ROOM. There were multiple unsealed penetrations and cut openings in the gypsum wall board at a drywall location just above the former door (this door is permanently closed).

Based on observations made during the survey of the facility between the hours of 3:00 pm and 6:00 pm, while accompanied by the Acting Administrator, System Manager Plant Ops, System Manager Security & EOC, and BioMed Director it was observed that the facility was utilizing a portion of the CORRIDOR near the NURSE STATION for storage. The open bin, wall-hung storage units are not acceptable within the CORRIDOR. A room must be provided for this purpose. Whether an existing room is utilized, or if a " new " room is constructed - in either case the following is required:
(A) IF ROOM EXCEEDS 100 SQUARE FEET - Any room for " storage " purposes which exceeds 100 square feet shall be a 1 hour fire-rated room. All walls must be 1 hour, and the door assembly (frame/door leaf/hardware) must be 45 minute fire-rated.
(B) WHEN ROOM IS 100 SQUARE FEET OR LESS - No fire rating is required in regards to the " storage " function. Where rated walls already exists, or are otherwise required, then the integrity of such walls is to be maintained.