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Tag No.: K0029
The facility failed to separate 2 of 4 hazardous areas from other spaces with a one-hour fire resistive rated floor/ceiling assembly.
Observation determined:
1) The membrane ceiling of the Medical Records Room had holes that were not sealed with fire rated material.
2) The membrane ceiling of the Central Storage Room had holes that were not sealed with fire rated material.
Tag No.: K0076
Freestanding oxygen cylinders must be properly chained or supported in a proper cylinder stand or cart. NFPA 99 9.7.2.3
The facility failed to secure all oxygen cylinders in the Home Health Oxygen Storage Room. Observation determined six free standing oxygen cylinders were not chained or supported.
Tag No.: K0130
The facility failed to maintain the emergency power supply system (EPSS) with all required components and provide a remote system alarm at a work site that is readily observable by personnel. NFPA 110, Standard for Emergency and Standby Power Systems.
Observation revealed the facility's emergency power supply (EPS) consisted of a generator located indoors and a transfer switch located in the Boiler Room. The Boiler Room was not continuously occupied and there was no annunciator panel installed at a location that was readily observed by staff.