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J PAUL JONES HOSPITAL
Hazardous Areas - Enclosure
Tag No.: K0321
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Based on observation and interview, the facility failed to provide separation from a hazardous area per the requirements of:
42 CFR 483.90 (a) (1) (ii)
2012 NFPA 101, 19.3.2.1.3
Findings include:
On 5/01/2018, during a tour of the facility from 10:30 am to 4:00 pm, the surveyor observed the corridor door to the Basement/Boiler Room, (this room has gas operating equipment and is over 50 sq. ft.) failed to positive latch.
A member of the maintenance staff was present when this deficiency was identified.
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Sprinkler System - Maintenance and Testing
Tag No.: K0353
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Based on review of documentation and interview, the facility failed to maintain the automatic sprinkler system riser gauges per the requirements of:
2012 NFPA 101, 19.3.5.1, and 9.7.5
2011 NFPA 25, 5.3.2.1, and 5.2.4.1
Findings include:
1. On 5/01/2018, during a tour of the facility from 10:30 am to 4:00 pm, the surveyor observed that the automatic sprinkler system riser gauges had not been calibrated or replaced within the past 5 years. The gauges were installed on 10/31/2011 per interview and documentation.
2. On 05/01/2018, during the review of documentation from 10:30 am to 4:00 pm, the facility failed to provide documentation of the monthly inspection for the wet gauges on the automatic sprinkler system riser.
A member of the maintenance staff was present when this deficiency was identified.
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39326
Subdivision of Building Spaces - Smoke Barrie
Tag No.: K0372
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Based on observation and interview, the facility failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and resist the passage of smoke per the requirements of:
2012 NFPA 101, 19.3.7.3, 8.5.1, and 8.5.6.3
Findings include:
On 05/01/2018, during a tour of the facility from 10:30 am to 4:00 pm, the surveyor observed orange non-fire rated foam sealant was used to seal penetrations in the smoke barrier above the ceiling inside the Fire Alarm Panel Room near the Nurses' Station.
A member of the maintenance staff was present when this deficiency was identified.
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Electrical Equipment - Power Cords and Extens
Tag No.: K0920
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Based on observation and interview, the facility failed to prohibit the use of extension cords per the requirements of:
2012 NFPA 99, 10.2.3.6, and 10.2.4
2011 NFPA 70, 400-8
S&C 14-46-LSC
On 5/01/2018, during a tour of the facility from 10:30 am to 4:00 pm, an extension cord was observed plugged into a power strip in the Business Office next to the Administrators Office.
A member of the maintenance staff was present when this deficiency was identified.