HospitalInspections.org

42 CFR 482.41(a)

Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The double door assembly to room #271 and #270 are equipped with manual flush bolts without self-closing devices - doors can not be closed and latched with a single hand motion.

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is no positive latching hardware on exit access door to Neonatologist office - proposed suite area enclosing office is not defined with access doors to suite equipped with postive latching hardware.

2. Doors to C-section suite are not equipped with positive latching hardware - located on third floor.

3. Door to staff breakroom is not equipped with positive latching hardware - located on third floor near C-section suite.


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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The an unapproved air transfer grill was installed in the smoke wall above the Flash Autoclave located in the OR central core.

2. The smoke wall between suite C and D above the corridor doors. Wall was not sealed smoke tight in order to maintain the fire resistance rating of the area.

3. The elevator lobby on third floor that opens to corridor outside Director of Woman's Services office was not constructed to provide a 1 hour barrier and arranged as a smoke barrier in accordance with NFPA 101 Section 8.3, and NFPA 101: 7.2.13.3


These deficiencies affected approximately seven 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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The mechanical/electrical storage room located next to the employee entrance was not 1-hour constructed.

2. There is no self-closing device for fire door to second floor storage room - room is located beside utility pipe chase.

3. Fire door to pharmacy supply is not self-closing and latching - inactive leaf uses manual flush bolt assembly - room is located on the first floor near front entrance.

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Lack of complete special locking arrangement installation for exit door at stairwell #3 - there is no on/off release switch not greater than three feet from door.

2. Lack of complete special locking arrangement installation for exit door at stairwell #3 - the master on/off switch at supervised nurse's station would not release locking arrangement at referenced area in the off position.

3. Lack of complete special locking arrangement installation for lobby smoke door beside Director of Women's Services office - there is no on/off switch not greater than three feet from exit access doors.

4. Lack of complete special locking arrangement installation for cross corridor doors beside room RA130 - there is no master on/off switch at a supervised station in the Radiology area.


This deficiency affected two 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.

Note: All electromagnetic locking arrangements released doors with activation of the facility smoke detection system and loss of power during test.

42 CFR 482.41(a)

Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Fire door to south stairwell will not self-close and latch - located on third floor.

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Doors to C-section suite are a pair of doors less than 41.5 inches - doors as arranged require greater than a single motion of the hand to open, close and latch - located on third floor.

2. In the material management storage room there is a storage area that has a steel and wire mesh door frame the was equipped with a pad lock that would prevent an individual from exiting when locked in case of an emergency.

3. The master override switch located at the employee entrance and for the De-con Room in the OR suite did not operate when tested.

4. Doors to the walk-in coolers and freezers are equipped with non-passage hardware. Lock sets allow occupants to be locked inside units in the kitchen area.

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There are no emergency light(s) in third floor nursery room containing exit access doors equipped with electromagnetic locking arrangement - method of door release is not obvious in darkness.

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The smoke duct detectors located in the AHU #2.1 unit return in the 2nd floor mechanical room were not maintained clean and in good operating condition. Device had excessive dust accumulation on the air sampling tube ports. NFPA 90 A 4-4.4.1


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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The smoke duct detectors located in the AHU #8 unit return in the third floor mechanical room were not maintained clean and in good operating condition. Device had excessive dust accumulation on the air sampling tube ports. NFPA 90 A 4-4.4.1

2. The smoke duct detector, located on AHU #19, in second floor mechanical room has excessive dust accumulation on air sampling tube ports. NFPA 90A 4-4.4.1

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

Facility utilizes special locking on doors in the facility and it was determined that the building was not protected throughout by an approved, supervised automatic fire detection system in accordance with NFPA 101: Section 9.6, or an approved, supervised automatic sprinkler system in accordance with NFPA 101 Section 9.7.
NFPA 101: 7.2.1.6.1

1. The hydraulic elevators do not have sprinkler head installed at the bottom of each elevator hoistway not more than 2 ft. (0.61 m) above the floor of the pit as specified by NFPA 13.5-13.6

2. The recessed can wash located on the rear loading dock is not provided sprinkler coverage.

3. The closet in the linen storage room on 1st floor is not provided with sprinkler coverage.

4. The top of the stairwells, throughout the facility, were not provided with sprinkler coverage.

5. The 1st, 2nd and 3rd mechanical room have upright sprinkler heads installed above the ducts and in multiple area they are blocked by pipes and HVAC ducts where they do not provide complete coverage below.


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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Main sprinkler valves did not generate a tamper switch supervisory signal with the valves in closed position - located in valve pit at driveway entrance in front of hospital.

2. Main sprinkler valves are covered with rust - pit located at front entrance driveway.


This deficiency affected all 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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The tamper switch audible signal can be permanently silenced with the sprinkler valves in the closed position - located in medical office building at fire alarm panel.

This deficiency affected two 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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The sprinkler heads located in 1st, 2nd, 3rd, mechanical rooms and elevator equipment room have sprinkler heads rated for Intermediate Temperature Classification, Glass Bulb Color of Green (200°F) in place of Ordinary Temperature Classification, Glass Bulb Color of Orange temperature rating of (135°F) or Red (155°F). All four areas are air conditioned spaces.

2. In the 3rd floor mechanical room there are sprinkler heads rated for intermediate and ordinary temperature classification.

3. On the loading dock the recessed sprinkler covers were not maintained in good condition. Several were sealed to the ceiling, one was tapped over and one was blocked with sheet rock and missing cover.

4. Scattered throughout the the facility, in rooms and corridors, sprinkler heads were found to have lint and dust accumulation on the heat sensitive element.

5. The upright sprinklers are obstructed by piping systems in the utility pipe chase located on the second floor.

6. The upright sprinkler is obstructed by plumbing pipes in the water heater storage room - located in kitchen.

These deficiencies affected the entire facility.
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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. An access door was not provided for in the 2-hour rated wall in the 3rd floor mechanical room in order to allow for testing and inspection of the smoke/fire damper located in the HVAC duct for the vertical penetration.

2. In the Boiler room, Surgery suite, the HVAC duct were not properly secured. One was draped over a light fixture and another was hanging down just inside the room.

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is non-medical equipment stored in the corridor area near room 273.

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There are oxygen cylinders stored less than five feet from combustible storage items in ER clean linen supply and equipment room - located on first floor.

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The generator annunciator panel is not located in a supervised location of the main hospital.

2. The generator annunciator panel failed to read generator set supplying load during loss of normal power to the automatic transfer switch for the Life Safety Branch systems.

3. The Life Safety Branch panelboard, 1 L/E, contains equipment not permitted by NFPA 99 and Article 517 of the National Electrical Code. Air compressors and day tank circulation pump are not permitted to be wired to the Life Safety Branch system.

4. Extension cord with receptacle is wired to the critical branch panelboard 1 Q/E, in main central plant, as circuits #8, and #10. All circuits shall be wired in metal raceway.

5. Emergency power connected to load visual indicator did not function for fire pump transfer switch with loss of normal power to switch - located in sprinkler fire pump area.

6. Unitary light in generator room did not function with loss of normal power to fixture - located above day tank for generator.

7. Critical branch lighting switches at nurses station in third floor Post Partum can not be distinguished from normal power switches.

This deficiency potentially affected all 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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Leak sensors for UL 142 double wall, above ground, generator fuel tank are disconnected from supply circuits.

2. Circuit breaker and emergency panel supplying power to SHP equipment is not identified on single hazard panels located in rooms containing referenced systems.

3. The switch cover located in procedure room #1, 1st floor was cracked and not maintained in good condition.

This deficiency affected potentially all 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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The double door assembly to room #271 and #270 are equipped with manual flush bolts without self-closing devices - doors can not be closed and latched with a single hand motion.

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is no positive latching hardware on exit access door to Neonatologist office - proposed suite area enclosing office is not defined with access doors to suite equipped with postive latching hardware.

2. Doors to C-section suite are not equipped with positive latching hardware - located on third floor.

3. Door to staff breakroom is not equipped with positive latching hardware - located on third floor near C-section suite.


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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The an unapproved air transfer grill was installed in the smoke wall above the Flash Autoclave located in the OR central core.

2. The smoke wall between suite C and D above the corridor doors. Wall was not sealed smoke tight in order to maintain the fire resistance rating of the area.

3. The elevator lobby on third floor that opens to corridor outside Director of Woman's Services office was not constructed to provide a 1 hour barrier and arranged as a smoke barrier in accordance with NFPA 101 Section 8.3, and NFPA 101: 7.2.13.3


These deficiencies affected approximately seven 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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The mechanical/electrical storage room located next to the employee entrance was not 1-hour constructed.

2. There is no self-closing device for fire door to second floor storage room - room is located beside utility pipe chase.

3. Fire door to pharmacy supply is not self-closing and latching - inactive leaf uses manual flush bolt assembly - room is located on the first floor near front entrance.

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Lack of complete special locking arrangement installation for exit door at stairwell #3 - there is no on/off release switch not greater than three feet from door.

2. Lack of complete special locking arrangement installation for exit door at stairwell #3 - the master on/off switch at supervised nurse's station would not release locking arrangement at referenced area in the off position.

3. Lack of complete special locking arrangement installation for lobby smoke door beside Director of Women's Services office - there is no on/off switch not greater than three feet from exit access doors.

4. Lack of complete special locking arrangement installation for cross corridor doors beside room RA130 - there is no master on/off switch at a supervised station in the Radiology area.


This deficiency affected two 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.

Note: All electromagnetic locking arrangements released doors with activation of the facility smoke detection system and loss of power during test.

42 CFR 482.41(a)

Based on observations, on June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Fire door to south stairwell will not self-close and latch - located on third floor.

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Doors to C-section suite are a pair of doors less than 41.5 inches - doors as arranged require greater than a single motion of the hand to open, close and latch - located on third floor.

2. In the material management storage room there is a storage area that has a steel and wire mesh door frame the was equipped with a pad lock that would prevent an individual from exiting when locked in case of an emergency.

3. The master override switch located at the employee entrance and for the De-con Room in the OR suite did not operate when tested.

4. Doors to the walk-in coolers and freezers are equipped with non-passage hardware. Lock sets allow occupants to be locked inside units in the kitchen area.

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There are no emergency light(s) in third floor nursery room containing exit access doors equipped with electromagnetic locking arrangement - method of door release is not obvious in darkness.

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The smoke duct detectors located in the AHU #2.1 unit return in the 2nd floor mechanical room were not maintained clean and in good operating condition. Device had excessive dust accumulation on the air sampling tube ports. NFPA 90 A 4-4.4.1


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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The smoke duct detectors located in the AHU #8 unit return in the third floor mechanical room were not maintained clean and in good operating condition. Device had excessive dust accumulation on the air sampling tube ports. NFPA 90 A 4-4.4.1

2. The smoke duct detector, located on AHU #19, in second floor mechanical room has excessive dust accumulation on air sampling tube ports. NFPA 90A 4-4.4.1

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

Facility utilizes special locking on doors in the facility and it was determined that the building was not protected throughout by an approved, supervised automatic fire detection system in accordance with NFPA 101: Section 9.6, or an approved, supervised automatic sprinkler system in accordance with NFPA 101 Section 9.7.
NFPA 101: 7.2.1.6.1

1. The hydraulic elevators do not have sprinkler head installed at the bottom of each elevator hoistway not more than 2 ft. (0.61 m) above the floor of the pit as specified by NFPA 13.5-13.6

2. The recessed can wash located on the rear loading dock is not provided sprinkler coverage.

3. The closet in the linen storage room on 1st floor is not provided with sprinkler coverage.

4. The top of the stairwells, throughout the facility, were not provided with sprinkler coverage.

5. The 1st, 2nd and 3rd mechanical room have upright sprinkler heads installed above the ducts and in multiple area they are blocked by pipes and HVAC ducts where they do not provide complete coverage below.


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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Main sprinkler valves did not generate a tamper switch supervisory signal with the valves in closed position - located in valve pit at driveway entrance in front of hospital.

2. Main sprinkler valves are covered with rust - pit located at front entrance driveway.


This deficiency affected all 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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The tamper switch audible signal can be permanently silenced with the sprinkler valves in the closed position - located in medical office building at fire alarm panel.

This deficiency affected two 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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The sprinkler heads located in 1st, 2nd, 3rd, mechanical rooms and elevator equipment room have sprinkler heads rated for Intermediate Temperature Classification, Glass Bulb Color of Green (200°F) in place of Ordinary Temperature Classification, Glass Bulb Color of Orange temperature rating of (135°F) or Red (155°F). All four areas are air conditioned spaces.

2. In the 3rd floor mechanical room there are sprinkler heads rated for intermediate and ordinary temperature classification.

3. On the loading dock the recessed sprinkler covers were not maintained in good condition. Several were sealed to the ceiling, one was tapped over and one was blocked with sheet rock and missing cover.

4. Scattered throughout the the facility, in rooms and corridors, sprinkler heads were found to have lint and dust accumulation on the heat sensitive element.

5. The upright sprinklers are obstructed by piping systems in the utility pipe chase located on the second floor.

6. The upright sprinkler is obstructed by plumbing pipes in the water heater storage room - located in kitchen.

These deficiencies affected the entire facility.
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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. An access door was not provided for in the 2-hour rated wall in the 3rd floor mechanical room in order to allow for testing and inspection of the smoke/fire damper located in the HVAC duct for the vertical penetration.

2. In the Boiler room, Surgery suite, the HVAC duct were not properly secured. One was draped over a light fixture and another was hanging down just inside the room.

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is non-medical equipment stored in the corridor area near room 273.

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There are oxygen cylinders stored less than five feet from combustible storage items in ER clean linen supply and equipment room - located on first floor.

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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The generator annunciator panel is not located in a supervised location of the main hospital.

2. The generator annunciator panel failed to read generator set supplying load during loss of normal power to the automatic transfer switch for the Life Safety Branch systems.

3. The Life Safety Branch panelboard, 1 L/E, contains equipment not permitted by NFPA 99 and Article 517 of the National Electrical Code. Air compressors and day tank circulation pump are not permitted to be wired to the Life Safety Branch system.

4. Extension cord with receptacle is wired to the critical branch panelboard 1 Q/E, in main central plant, as circuits #8, and #10. All circuits shall be wired in metal raceway.

5. Emergency power connected to load visual indicator did not function for fire pump transfer switch with loss of normal power to switch - located in sprinkler fire pump area.

6. Unitary light in generator room did not function with loss of normal power to fixture - located above day tank for generator.

7. Critical branch lighting switches at nurses station in third floor Post Partum can not be distinguished from normal power switches.

This deficiency potentially affected all 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 June 9 - 11, 2015 at approximately 5:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Leak sensors for UL 142 double wall, above ground, generator fuel tank are disconnected from supply circuits.

2. Circuit breaker and emergency panel supplying power to SHP equipment is not identified on single hazard panels located in rooms containing referenced systems.

3. The switch cover located in procedure room #1, 1st floor was cracked and not maintained in good condition.

This deficiency affected potentially all smoke compartments.

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