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915 RIVER ROAD

MIDDLETOWN, CT 06457

No Description Available

Tag No.: K0025

The facility did not ensure that smoke barriers were constructed to provide at least a one-hour fire resistance rating in accordance with 8.3. Smoke barriers may terminate at an atrium wall as required by the referenced LSC 18.3.7.3, 18.3.7.5, 18.1.6.3

On 12/07/15 and 12/08/15 at 09:00 and at times throughout the day, the surveyor along with the Plant Facilities Engineer 1 and Environment of Care Coordinator observed that the smoke barrier walls above the suspended ceiling assembly for the corridor smoke doors, and walls in the connector tunnels had voids and penetrations used for the passage of wires, conduit, etc. that were not sealed with materials having at least a half hour fire resistance rating as required.

No Description Available

Tag No.: K0050

The facility did not ensure that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the referenced LSC.

On 12/07/15 and 12/08/15 at 09:00 and at times throughout the day, the surveyor was not provided with documentation by the Plant Facilities Engineer 1 and Environment of Care Coordinator that fire drills were conducted on the 3rd shift in the 1st and 3rd quarters of 2015.

No Description Available

Tag No.: K0062

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC.

On 12/08/15 at 1:00 PM, the surveyor while accompanied by the Plant Facilities Engineer 1 and Environment of Care Coordinator observed that the dry pendant sprinkler heads in the walk in coolers and freezers were dated 1993 and had not been changed as required by NFPA 25 for dry pendant sprinkler heads every 10 years.

No Description Available

Tag No.: K0130

1. The facility did not ensure that electrical receptacle outlets in patient areas were maintained as required in NFPA 99 " Health Care Facilities " Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program.

On 12/08/15 at 9:30 AM, the surveyor was not provided with documentation by the Plant Facilities Engineer 1 and Environment of Care Coordinator that electrical receptacle outlets in-patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program.

2. The facility did not ensure that Emergency and Standby Power Systems were being inspected and maintained as required in NFPA 110 " Standard for Emergency and Standby Power Systems " .

On 12/08/15 at 09:30 AM, The surveyor was not provided with documentation by Plant Facilities Engineer 1 and Environment of Care Coordinator that the facilities emergency generator was being maintained as required by NFPA 110 " Standard for Emergency and Standby Power Systems " i.e. the ventilation louvers identified on the 03/04/15 and 08/24/15 Advance Power maintenance report had been repaired and or replaced as required.

No Description Available

Tag No.: K0144

The facility failed to ensure that a remote annunciator for the facilities emergency generator was installed at a staffed location as required in NFPA 99 " Health Care Facilities " Section 3-4.1.1.15(a) and (b)

On 12/08/15 at 10:00 AM, the surveyor while accompanied by the Plant Facilities Engineer 1 and Environment of Care Coordinator toured the facility generator enclosure and interview revealed that the generator lacks a remote annunciator observed to indicate that the facility generator is in an off normal state or running and providing power.