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42 CFR 482.41(a)

Based on observations, on 6/2/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The fire door to the clean linen storage room is tied in the open position - fire door must be self-closing and latching without manual intervention. Room of reference is located off exit corridor leading to loading dock.

2. There is a wedge under fire door to environmental housekeeping room - room is located off hallway leading to kitchen.

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 6/2/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There is an incomplete electromagnetic locking system used on access door between outpatient surgery office and intensive care unit. The lock is not equipped with switching arrangements, and complete building sprinkler or detection system as described in section 7-2.1.6 of NFPA 101; 2000 Life Safety Code.


This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 6/2/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is no exit directional sign for corridor exit sign located near dining room area - existing sign directs occupants toward dining room and not toward exit discharge near loading dock.

2. There is no exit directional sign for exit discharge serving the ER entrance waiting area - existing sign is not equipped with chevron directing occupants to appropriate exit.


This deficiency affected one of three smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 6/2/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is no smoke detector provided not greater than five feet from smoke barrier located near room 706.

This deficiency affected one of three smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 6/2/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

The exit discharge path is obstructed by wood pallets and other impediments at loading dock area near room 609.

This deficiency affected three of three smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 6/2/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There are oxygen cylinders store less than five feet from combustible storage in future elevator shaft storage room. Room is identified as room 1215.


This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 6/2/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The essential electrical system failed to restore power in not greater than ten seconds during loss of normal power to the Life Safety Branch transfer switch. The system required sixteen seconds to restore power during test.

2. The generator annunciator panel failed to read generator supplying load during test of the essential electrical system as stated in item #1.

3. There is no task lighting with unitary equipment at access panels to the emergency generator - the lighting must be connected to the essential electrical system in accordance with NFPA 99 and NFPA 70.


This deficiency potentially affected all smoke compartments and resident use areas.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 6/2/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is an exposed bulb light fixture above storage items in biohazard room - located in ER area.

2. There is less than three feet clearance maintained in front of electrical panels - located in ICU equipment room.


This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 6/2/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The fire door to the clean linen storage room is tied in the open position - fire door must be self-closing and latching without manual intervention. Room of reference is located off exit corridor leading to loading dock.

2. There is a wedge under fire door to environmental housekeeping room - room is located off hallway leading to kitchen.

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 6/2/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There is an incomplete electromagnetic locking system used on access door between outpatient surgery office and intensive care unit. The lock is not equipped with switching arrangements, and complete building sprinkler or detection system as described in section 7-2.1.6 of NFPA 101; 2000 Life Safety Code.


This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 6/2/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is no exit directional sign for corridor exit sign located near dining room area - existing sign directs occupants toward dining room and not toward exit discharge near loading dock.

2. There is no exit directional sign for exit discharge serving the ER entrance waiting area - existing sign is not equipped with chevron directing occupants to appropriate exit.


This deficiency affected one of three smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 6/2/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is no smoke detector provided not greater than five feet from smoke barrier located near room 706.

This deficiency affected one of three smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 6/2/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

The exit discharge path is obstructed by wood pallets and other impediments at loading dock area near room 609.

This deficiency affected three of three smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 6/2/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There are oxygen cylinders store less than five feet from combustible storage in future elevator shaft storage room. Room is identified as room 1215.


This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 6/2/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The essential electrical system failed to restore power in not greater than ten seconds during loss of normal power to the Life Safety Branch transfer switch. The system required sixteen seconds to restore power during test.

2. The generator annunciator panel failed to read generator supplying load during test of the essential electrical system as stated in item #1.

3. There is no task lighting with unitary equipment at access panels to the emergency generator - the lighting must be connected to the essential electrical system in accordance with NFPA 99 and NFPA 70.


This deficiency potentially affected all smoke compartments and resident use areas.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 6/2/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is an exposed bulb light fixture above storage items in biohazard room - located in ER area.

2. There is less than three feet clearance maintained in front of electrical panels - located in ICU equipment room.


This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.