HospitalInspections.org

42 CFR 483.70 (a)

Based on observations, on 6/3/2015 at approximately 9:00 AM onward, the following deficiencies were noted:

The facility failed to have proper separation of a hazardous area.

1. The facilty does not have the bottom portion of the inactive leaf or the door (1019) for the storage room connected on the top and bottom of the door in the community room.

2. The facilty does not have the bottom portion of the inactive leaf or the door (1133a) at the emergency department.

3. The facilty does not have the bottom portion of the inactive leaf or the door at the radiology department.


Ref: NFPA 80 Section 6.1

42 CFR 483.70 (a)

Based on observations, on 6/3/2015 at approximately 9:00 AM onward, the following deficiencies were noted:

The facility failed to meet the requirements for egress paths.

1. The facilty does not have a clear exit path to from the materials management hallway to the public way.

2. The exit path from the consult area leading to the main lobby does not have an eight foot clear path.

This deficiency affected the two egress corridor of approximently 6 egress corridors.

Ref: NFPA 101 Section 18.2.1

42 CFR 483.70 (a)

Based on observations, on 6/3/2015 at approximately 9:00 AM onward, the following deficiencies were noted:

The facility failed to have proper exit directional signs in the egress corridors.

The facilty does not have two visible exit directional signs near room 1314 leading from the operating rooms to the emergency department of the hospital.

This deficiency affected the one egress corridor of approximently 6 egress corridors.

Ref: NFPA 101 section 7.10.1

42 CFR 483.70 (a)

Based on observations, on 6/3/2015 at approximately 9:00 AM onward, the following deficiencies were noted:

The facility failed to have proper heating for the sprinkler system.

The facilty does not have heating in the sprinkler riser room (1055) with outside entry. This location did not proper heating on the emergency circuit to prevent freezing of the sprinkler system and its components.

The deficiency would allow the sprinkler pipes to be susceptible to freezing in very low ambient temperatures.

This deficiency affected the one sprinkler riser room for the facility.

Ref: NFPA 13 Section 8.16.4

42 CFR 483.70 (a)

Based on observations, on 6/4/2015 at approximately 1:00 PM onward, the following deficiencies were noted:

The facility failed to meet the requirements for generator components being installed.

The emergency generator located on the exterior of the building has no remote manual stop switch located outside the generator set location.

This deficiency affected the entire facility as the generator supplies the entire facility's emergency power souse.

Ref: 2000 NFPA 101, 110, 3-5.5.6

42 CFR 483.70 (a)

Based on observations, on 6/3/2015 at approximately 9:00 AM onward, the following deficiencies were noted:

The facility failed to have proper separation of a hazardous area.

1. The facilty does not have the bottom portion of the inactive leaf or the door (1019) for the storage room connected on the top and bottom of the door in the community room.

2. The facilty does not have the bottom portion of the inactive leaf or the door (1133a) at the emergency department.

3. The facilty does not have the bottom portion of the inactive leaf or the door at the radiology department.


Ref: NFPA 80 Section 6.1

42 CFR 483.70 (a)

Based on observations, on 6/3/2015 at approximately 9:00 AM onward, the following deficiencies were noted:

The facility failed to meet the requirements for egress paths.

1. The facilty does not have a clear exit path to from the materials management hallway to the public way.

2. The exit path from the consult area leading to the main lobby does not have an eight foot clear path.

This deficiency affected the two egress corridor of approximently 6 egress corridors.

Ref: NFPA 101 Section 18.2.1

42 CFR 483.70 (a)

Based on observations, on 6/3/2015 at approximately 9:00 AM onward, the following deficiencies were noted:

The facility failed to have proper exit directional signs in the egress corridors.

The facilty does not have two visible exit directional signs near room 1314 leading from the operating rooms to the emergency department of the hospital.

This deficiency affected the one egress corridor of approximently 6 egress corridors.

Ref: NFPA 101 section 7.10.1

42 CFR 483.70 (a)

Based on observations, on 6/3/2015 at approximately 9:00 AM onward, the following deficiencies were noted:

The facility failed to have proper heating for the sprinkler system.

The facilty does not have heating in the sprinkler riser room (1055) with outside entry. This location did not proper heating on the emergency circuit to prevent freezing of the sprinkler system and its components.

The deficiency would allow the sprinkler pipes to be susceptible to freezing in very low ambient temperatures.

This deficiency affected the one sprinkler riser room for the facility.

Ref: NFPA 13 Section 8.16.4

42 CFR 483.70 (a)

Based on observations, on 6/4/2015 at approximately 1:00 PM onward, the following deficiencies were noted:

The facility failed to meet the requirements for generator components being installed.

The emergency generator located on the exterior of the building has no remote manual stop switch located outside the generator set location.

This deficiency affected the entire facility as the generator supplies the entire facility's emergency power souse.

Ref: 2000 NFPA 101, 110, 3-5.5.6