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STOUGHTON HOSPITAL
No Description Available
Tag No.: K0130
Based on observation and interview, the facility failed to provide stairwells that were protected from hazards identified in the code.
FINDINGS INCLUDE:
On 11/16/2011 at 3:30 pm surveyor #12187 observed in smoke compartment #9 on the lower level by the exit stair in the 1956 building that the LL326 belt room was an unoccupied room which opened into the stairwell enclosure. The room contained a supply of V-Belts, metal maintenance parts, and two 400A electrical disconnects. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Plant Operation).
This observation was also made during the original recertification survey on January 5, 2011 and the 1st verifcation visit of March 31, 2011. The facility's Plan of Correction was to request a hardship waiver. A waiver request has been processed and sent to CMS with recommendation that it be accepted.