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NORTH RUNNELS HOSPITAL
Means of Egress Requirements - Other
Tag No.: K0200
The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:30 pm to 4:00 pm on 04/02/2025 that the annual fire rated door inspection was past due. The last door inspection was conducted on 02/16/2023.
Protection - Other
Tag No.: K0300
The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:30 pm to 4:00 pm on 04/02/2025 that the sprinkler head 18-inch clearance rule was violated in Central Storage.
"The clearance between the deflector and the top of storage shall be 18-inches or greater." - NFPA 13, 2010: 8.5.6.1.
Interior Wall and Ceiling Finish
Tag No.: K0331
The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:30 pm to 4:00 pm on 04/02/2025 that flame spread documents for interior wall and ceiling finishes were not available for review.
Draperies, Curtains, and Loosely Hanging Fabr
Tag No.: K0751
The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:30 pm to 4:00 pm on 04/02/2025 that flame spread documents for Draperies, Curtains, and Loosely Hanging Fabrics were not available for review.
Gas Equipment - Cylinder and Container Storag
Tag No.: K0923
The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 1:30 pm to 4:00 pm on 04/02/2025 that oxygen cylinders were being stored in a non-ventilated and non-fire rated closet. The hospital must verify that the combined volume of these cylinders does not exceed 3,000 cubic feet.
Storage must also meet the following requirements.
Storage ? 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. (Min. 1 hour enclosure)
> 300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
? 300 cubic feet in a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of ? 300 cubic feet are not required to be stored in an enclosure.