HospitalInspections.org

The facility did not ensure that atriums are separated with construction having a fire resistance rating of at least one hour as required by the referenced LSC 8.2.4 (2) & 8.2.5.6.

On 01/14/16 at 11:45 AM and times throughout the day, the surveyor and Director of Facilities observed that the separation wall to the atrium on the second floor of the Milne Building had voids and penetrations above the suspended ceiling assembly for the enclosure from the atrium in the satellite gym that were not sealed using a UL approved system for fire stopping one (1) hour enclosures.

The facility did not ensure that hazardous areas were either separated by construction providing at least a one hour fire resistance rating or protected by an automatic extinguishing system, where the sprinkler option is used the areas shall be separated by smoke resisting partitions and self-closing doors as required by the LSC

On 01/14/16 at 10:30 AM and times throughout the day, the surveyor, accompanied by the Director of Facilities, observed that the corridor doors for the 1st and 2nd floor shower rooms that had been converted into storage rooms had two leaf doors that had a gap between the leafs in excess of ¿ inch and lacked door closer's not maintaining resistance to the passage of smoke and fire.

K 069
The facility did not ensure that the design, installation and use of its commercial cooking equipment were in accordance with NFPA 96, " Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations " & NFPA 54 National Fuel Gas Code as required by the referenced " Life Safety Code " .

On 01/15/16 at 10:40 AM, the surveyor, while accompanied by the Director of Facilities, observed that not all the wheeled, natural gas-fired cooking appliances located on the cooking line in the kitchen had the provided restraint system connected to prevent damage to the flexible, fuel lines-as required by NFPA 96 & 54 and one (1) had the restraint system wrapped around the flexible gas line.

The facility did not ensure that nonflammable medical gas systems and equipment used for the administration of inhalation therapy and for resuscitative purposes was in compliance with NFPA 99: Heath Care Facilities 8-3.1.11.

On 01/14/16 at 10:00 AM, the surveyor accompanied by the Director of Facilities observed that the facility was storing nine (9) liquid oxygen portable units on Rubbermaid wheeled carts in a storage room filled with combustible supplies and equipment covered with plastic bags i.e. Lyman 114 a patient room converted to storage.