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Based on observation, interview and review of record documents the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. These deficiencies in all of the 74 smoke compartments would affect all of the inpatients, outpatients, staff and visitors within the facility.

FINDINGS INCLUDED:

A-709: Based on the un-announced monitoring verification visit on 08/06/2015, the facility continues to be out of compliance in maintaining a safe environment from fire based on the following 14 K-tags.
· K-11 (building separation barrier);
· K-12 (building type construction);
· K-17 (corridor wall assembly);
· K-18 (corridor door openings);
· K-20 (vertical opening or shaft);
· K-22 (exit signs);
· K-25 (smoke barrier assembly);
· K-27 (smoke barrier doors);
· K-29 (hazardous spaces);
· K-38 (exit access);
· K-39 (width of aisles or corridors serving as exit access);
· K-51 (fire alarm system with approved components, devices or equip. installed);
· K-67 (heating, ventilating & air conditioning system);
· K-74 (portable fire extinguishers);

Based on the cumulative effects of the above findings, 42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET.
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Based on observation, interview and review of record documents the hospital failed to be constructed, arranged, and maintained to ensure the patient life safety from fire. These deficiencies in all of the 74 smoke compartments would affect all of the inpatients, outpatients, staff and visitors within the facility.

FINDINGS INCLUDED:

A-709: Based on the un-announced monitoring verification visit on 08/06/2015, the facility continues to be out of compliance in maintaining a safe environment from fire based on the following 14 K-tags.
· K-11 (building separation barrier);
· K-12 (building type construction);
· K-17 (corridor wall assembly);
· K-18 (corridor door openings);
· K-20 (vertical opening or shaft);
· K-22 (exit signs);
· K-25 (smoke barrier assembly);
· K-27 (smoke barrier doors);
· K-29 (hazardous spaces);
· K-38 (exit access);
· K-39 (width of aisles or corridors serving as exit access);
· K-51 (fire alarm system with approved components, devices or equip. installed);
· K-67 (heating, ventilating & air conditioning system);
· K-74 (portable fire extinguishers);

Based on the cumulative effects of the above findings, 42 CFR 482.41(b) Life Safety from Fire was NOT MET.
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