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64 ROBBINS ST

WATERBURY, CT 06721

No Description Available

Tag No.: K0011

The facility did not ensure that the common wall of the non-conforming building was a fire barrier having at least a two-hour fire resistance rating as required by the referenced LSC.

On 10/05/10 at 2:00 PM, the surveyor while accompanied by the Engineering Department Volunteer and the Engineering Technician observed that the 2-hour barrier between the Pomeroy Building and the Main Building contained voids and penetrations that were not patched and sealed with materials having a 2-hour fire resistance rating; i.e. large pieces of masonry block removed in storage area for empty, rigid metal conduit installation.

No Description Available

Tag No.: K0018

The facility did not ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1? inch sold-bonded core wood, capable of resisting the passage of smoke.

1. On 10/04/10 at 09:45 AM, the surveyor while accompanied by the Operating Room Staff observed that the Anesthesia Work Room door had holes on the workroom side of the door that damaged the core of the door.

2. On 10/04/10 at 11:15 AM, the surveyor while accompanied by the Operating Room Staff and the Engineering Technician observed that the door to Reed Operating Room #5 was binding at the frame and failed to close & latch.

3. On 10/04/10 at 11:05 AM, the surveyor while accompanied by the Operating Room Staff and the Engineering Technician observed that the door to Equipment Storage Room # 1634 in the Reed Operating corridor was binding at the frame and failed to close & latch.

No Description Available

Tag No.: K0025

The facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.

1. On 10/04/10 at 10:30 AM, the surveyor while accompanied by the Assistant Director of Engineering and the Engineering Technician observed that the smoke barriers located on floors 1, 5 & 9 were not being inspected and maintained; i.e. surveyors not allowed to inspect smoke barriers above the ceilings because of the presence of asbestos, although during previous inspections there was no such restriction.

2. On 10/04/10 at 11:03 AM, the surveyor while accompanied by the Assistant Director of Engineering and the Engineering Technician observed that the smoke barrier located on floor 7 and 8 of the Pomeroy Building contained gaps and voids around penetrations that were not sealed with materials having a 30-minute fire resistance rating; i.e. large holes in drywall above ceiling in patient rooms 7012 & 7029 & 8039.

3. On 10/05/10 at 09:50 AM, the surveyor while accompanied by the Engineering Department Volunteer and the Engineering Technician observed that the smoke barrier located on floor 3 of the Pomeroy Building contained gaps and voids around penetrations that were not sealed with materials having a 30-minute fire resistance rating; i.e. the cable raceway passing through smoke barrier above the corridor ceiling outside room #3029 has voids around the cables that are not sealed with fire rated materials. The square metallic electrical raceway was sealed with RTV silicone type materials and not the appropriate fire/smoke resistant materials required.

4. On 10/04/10 at 1:30 PM, the surveyor while accompanied by the Engineering Department Volunteer and the Engineering Technician observed that the smoke barriers located in the Emergency Department (Pomeroy Ground) contained voids around penetrations, above the ceiling that were not properly protected with materials having a 30-minute fire resistance rating.

5. On 10/04/10 at 1:15 PM, the surveyor while accompanied by the Engineering Technician observed multiple penetrations in the smoke barrier wall, near patient room #8103 & room # 8139 located within Behavioral Health that were not sealed with materials having a 30-minute fire resistance rating.

6. On 10/05/10 at 1:45 PM, the surveyor while accompanied by the Engineering Technician observed the gaps between the double-fire rated door assembly separating the Dietary Department Kitchen and the Dietary Department Storeroom was greater than the 1/8 " allowed by the LSC.

7. On 10/05/10 at 1:35 PM, the surveyor while accompanied by the Engineering Technician observed the fire barrier marked and identified as M206 (Pomeroy 2) had multiple voids around penetrations that were not sealed with materials having a 30-minute fire rating.

No Description Available

Tag No.: K0029

The facility did not ensure that hazardous areas were either separated by construction providing at least a one hour fire resistance rating or protected by an automatic extinguishing system, where the sprinkler option is used the areas shall be separated by smoke resisting partitions and self closing doors as required by 19.3.2.1

1. On 10/04/10 at 1:56 PM, the surveyor while accompanied by the Assistant Director of Engineering and the Engineering Technician observed that cables were routed through the wall of the electrical closets 4062 & 8103 in a cable tray -into the exit access corridor, were not protected with materials that were fire rated or could resist the passage of smoke; i.e. existing fire rated materials cleared away to allow new cables to be installed and not resealed with proper materials.

2. On 10/05/10 at 10:20 AM and at other times throughout the survey, the surveyor while accompanied by the Engineering Department Volunteer and the Engineering Technician observed that cables were routed through the wall of the electrical closets 3044 and 3062 in a cable tray -into the exit access corridor, and not protected with materials that were fire rated or could resist the passage of smoke; i.e. existing fire rated materials cleared away to allow new cables to be installed and not resealed with proper materials.

3. On 10/04/10 at 09:50 AM, the surveyor while accompanied by the Operating Room Staff observed that the fire rated door to the Pathology Laboratory was not equipped with a self-closing device.

4. On 10/05/10 at 10:30 AM, the surveyor while accompanied by the Engineering Technician observed that the walls and ceiling in the Carbon Dioxide Storage Room in the Main Laboratory (floor 2); have large holes in fire-rated barrier.

No Description Available

Tag No.: K0033

The facility did not ensure that exit components such as stairways were enclosed with construction having a fire resistance rating of at least two hours and were arranged to provide both a continuous path of escape and protection against fire or smoke from other parts of the building as required by the referenced LSC.

On 10/04/10 at 1:30 PM, the surveyor while accompanied by the Engineering Department Volunteer and the Engineering Technician observed penetrations around voids in the wall above the ceiling in stair enclosure by the Emergency Department Ambulance Exit (Pomeroy Ground).

No Description Available

Tag No.: K0046

The facility did not ensure that emergency lighting is provided in accordance with LSC 7.9 & 19.2.9.1.

On 10/06/10 at 1:45 PM, the surveyor were not provided with documentation that the emergency light fixtures are being tested & inspected monthly; i.e. No documentation that monthly (30 second) testing of the battery, emergency lights has occurred since July 2010.

No Description Available

Tag No.: K0073

The facility did not ensure that means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

1. On 10/05/10 at 1:30 PM, the surveyor while accompanied by the Engineering Department Volunteer and the Engineering Technician observed that the path from the base of exit stair #1 and the exit door at the loading dock in Pomeroy Building was not maintained free of obstructions that have the potential to impede egress; i.e. boxes, storage, pallets and other stored materials in the exit passageway.

2. On 10/04/10 at 1:00 PM, the surveyor while accompanied by the Engineering Department Volunteer observed that the exit-access corridor throughout the Emergency Department (Pomeroy Ground) was cluttered with items that impede egress; i.e. equipment, patient beds, photo copier, a desk with chair and hard wired computer.

No Description Available

Tag No.: K0074

The facility did not ensure that draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies are in accordance with provisions of NFPA 13, Standards for the Installation of Sprinkler Systems and NFPA 701.

1. On 10/04/10 at 11:02 AM, the surveyor while accompanied by the Assistant Director of Engineering and the Engineering Technician observed that the window curtains in all the patient rooms were equipped with no markings or tags that indicated a flame-resistance rating; nor was documentation provided by the Assistant Director of Engineering to indicate a rating.

2. On 10/04/10 at 1:15 PM, the surveyor while accompanied by the Assistant Director of Engineering and the Engineering Technician observed that the cubicle curtains in all the patient rooms were equipped with no markings or tags that indicated a flame-resistance rating; nor was documentation provided by the Assistant Director of Engineering to indicate a rating.

No Description Available

Tag No.: K0075

The facility did not ensure that solid linen or trash collection receptacles do not exceed 32 gal in capacity and mobile soiled linen or trash collection receptacles with capacities greater than 32 gal are located in a room protected as a hazardous area when not attended as required by the referenced LSC.

On 10/04/10 at 10:55 AM and at different dates & times throughout the survey, the surveyor while accompanied by the Assistant Director of Engineering, the Engineering Department Volunteer and the Engineering Technician observed that the mobile soiled linen or trash collection receptacles with capacities greater than 32 gal were not located in a room protected as a hazardous area when not attended as required by the referenced LSC; i.e. open-top, soiled linen carts observed throughout the exit-access corridors on floors 3, 4, 5, 7, 9 and in the Cardiac Wing on Ground and outside Dietary on floor 1.

No Description Available

Tag No.: K0076

The facility did not ensure that nonflammable medical gas systems and equipment used for the administration of inhalation therapy and for resuscitative purposes was in compliance with NFPA 99: Heath Care Facilities.

1. On 10/05/10 at 1:40 & 1:43 PM, the surveyor while accompanied by the Engineering Department Volunteer and the Engineering Technician observed that the steel, high-pressure cylinders located in the outside, loading dock storage area and the inside, Gas Vault (P007A) were not restrained or secure; i.e. most tanks not secured by chains-left un hooked and laying on floor.

2. On 10/05/10 at 1:43 PM, the surveyor while accompanied by the Engineering Department Volunteer and the Engineering Technician observed that the access door to the emergency oxygen supply connection was not locked or secured; i.e. the system can be tampered with, also appears as deficiency on August 2010 Environmental Technology Associates Inspection Report.

No Description Available

Tag No.: K0130

The facility did not ensure that patient care electrical devices in-patient areas were being inspected as required in NFPA 99 " Health Care Facilities " .

On 10/06/10 at 1:30 PM, the surveyors were not provided with documentation from the Director of Engineering that indicated that all electrical devices in patient areas are inspected as required in NFPA 99, Section 7-5.1.3,7-5.2.2.1 and 7-6.2.1.2 and as part of the facilities preventive maintenance program; i.e. patient beds located in patient rooms 9017 (due 08/15/10), 5005 (due 08/13/10) & wheeled, Newborn Photography Unit (no label at all) located in Storage Room # 3058.