HospitalInspections.org

K-255 Based on observations made in the presence of the facility director on 04/24/2018 it was determined that the facility did not maintain the suite separation in accordance with NFPA 101 19.3.6.2.

This deficiency affected 1 of several smoke compartments.

Findings include:
During the facility tour it was observed that the suite separation wall in the corridor leading into the sleep lab had several penetrations of various sizes and not in accordance with NFPA 101 19.3.6.2, 19.2.5.7.1.2.

K-321 Based upon observations made in the presence of the facility director on 04-24-2018, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1, 19.3.2.1.1 through 19.3.2.1.5(18.3.2.1)

This deficiency affected 1 of several smoke compartments.

Findings include:
1- During the facility tour it was observed that the C.S. storage room door "bowling alley "did not have a self-closing device. The doors shall be self-closing or automatic-closing in accordance with NFPA 101 19.3.2.1.3.

K-511 Based upon observations made in the presence of the facility director on 04-24-2018, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2

This deficiency affected 1 of several smoke compartments.

Findings include:
During the facility tour exposed wiring was observed in the ER storage closet where the fluorescent light fixture was wired into the 4x4 junction box. Also the two 4x4 boxes did not have the required covers on them. Electrical equipment shall be maintained in accordance with NFPA 70.230.62 (A)

K-919 Based upon observations made in the presence of the facility director on 04-24-2018 it was observed that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1; 9.1.2, NFPA 70 210.8, 210.8(A) through (C), GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink.

This deficiency affected 1 of several smoke compartments.

Findings include:
1-During the facility tour it was observed that the pharmacy had outlets within the 6 ft. of the outside of the sink that are required to be GFIC labeled/protected outlets that were not and not in accordance with NFPA 101 Section 19.5.1, 9.1.2; 2011 NFPA 70 Article 210-8(7)

K-923 Based upon observations made in the presence of the facility director on 04-24-2018, it was determined that the facility did not maintain medical gas storage in accordance with NFPA 101 19.3.2.4.

This deficiency affected 1 of several smoke compartments.

Findings include:
During the facility tour two unsecured CO2 cylinders were observed in the physician lounge. Provisions shall be made to protect cylinders from accidental damage in accordance with NFPA 101 19.3.2.4 and NFPA 99 5.1.3.3.2 (7)