HospitalInspections.org

Based on observations during the tour at the facility on the morning of 7/14/2011, with the CEO and Corporation ' s VP and the Maintenance Director, the facility failed to assure the doors in smoke barriers had the required smoke control amenities. The opposite swing cross-corridor smoke doors did not have astragals installed to provide a smoke tight seal at the meeting edges of the doors when close.

Based on observations during the tour of the facility on the morning of 7/14/2011 with the CEO and Corporation ' s VP and the Maintenance Director, the facility failed to assure an acceptable enclosure of hazardous areas. A clean linen had been converted to a storage room of combustible material (i.e. cardboard boxes) and did not have a closure on the door. Ensure that either the room is converted back to clean linen or that this room has a 1-hour fire rated enclosure (1-hour fire rated walls with 3/4-hour fire rated door assemblies with closure on doors and astragal at doors).

Based on observations during the tour of the facility on the morning of 7/14/2011 with the CEO and Corporation ' s VP and the Maintenance Director, the facility failed to provide an exit sign marking the egress path out the building. The exit signs, located at the end of the east and west patient wing ' s egress corridors, were not visible because of a fur down. Exit, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

Based on observations during the tour of the facility on the morning of 7/14/2011 with the CEO and Corporation ' s VP and the Maintenance Director, the facility failed to conduct proper fire drills. Upon conducting fire drills, the facility shall pull a fire station to include the transmission of a fire alarm signal. Drills shall be conducted quarterly on each shift to familiarize the facility personnel with the signals and emergency action required under various conditions.

Based on observations during the tour of the facility on the morning of 7/14/2011 with the CEO and Corporation ' s VP and the Maintenance Director, the facility failed to provide, at emergency generator set location, a task illumination and an emergency receptacle. The light fixture(s) illuminating the generator set must be energized by battery power. The battery in turn must be charged by an electrical connection to a life safety branch panelboard. In addition an electrical outlet must be provided in proximity to the generator and this outlet must be circuited to a life safety branch panelboard. This receptacle is required to be red with the circuit and panelboard numbers on the receptacle ' s plate. Verify that the three conditions are in compliance