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A) From random observation, during the survey walk-through, the surveyor finds that use areas in corridors (or open to corridors) do not appear to comply with 19.3.6.1. exception #2.

1. Family waiting room located adjacent to the corridor outside of the Foot Clinic. This room is not supervised and remains open to the corridor. The area lacks smoke detection to comply with NFPA 72 and a self closing door.



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A) From random observation the surveyors find that Hazardous Areas are not enclosed in accordance with 19.3.2, and 8.4, where applicable:

1. Radiology Dept. A room is being used for "Bone Density", this room contains a wall of shelving with x-ray records in an amount that constitutes a hazardous area. Patient care appears to be taking place in a storage room.



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A). Based on document review, the facility's fire alarm system does not appear to be maintained to comply with 9.6.
It was noted that smoke detectors were functionally tested semi-annually. Seven detectors failed to pass the test, however, no corrective action was documented. Example locations:

1. The smoke detector for the hallway west of Physical Therapy, E.R. room # 2, Radiology by X-ray-1, Corridor by the DON office, with no documented repair to meet the requirements of NFPA 72 1999 edition 7-1.1.2.



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A) Based on document review, not all portions of the facility's automatic sprinkler system are inspected, tested and maintained to comply with NFPA 25 1998.

1. Documentation was not available at the time of the survey for the current inspection of the backflow preventor serving the Kidney Center.






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A). Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

A) From random observation, during the survey walk-through, the surveyor finds that use areas in corridors (or open to corridors) do not appear to comply with 19.3.6.1. exception #2.

1. Family waiting room located adjacent to the corridor outside of the Foot Clinic. This room is not supervised and remains open to the corridor. The area lacks smoke detection to comply with NFPA 72 and a self closing door.



.

A) From random observation the surveyors find that Hazardous Areas are not enclosed in accordance with 19.3.2, and 8.4, where applicable:

1. Radiology Dept. A room is being used for "Bone Density", this room contains a wall of shelving with x-ray records in an amount that constitutes a hazardous area. Patient care appears to be taking place in a storage room.



.

A). Based on document review, the facility's fire alarm system does not appear to be maintained to comply with 9.6.
It was noted that smoke detectors were functionally tested semi-annually. Seven detectors failed to pass the test, however, no corrective action was documented. Example locations:

1. The smoke detector for the hallway west of Physical Therapy, E.R. room # 2, Radiology by X-ray-1, Corridor by the DON office, with no documented repair to meet the requirements of NFPA 72 1999 edition 7-1.1.2.



.

A) Based on document review, not all portions of the facility's automatic sprinkler system are inspected, tested and maintained to comply with NFPA 25 1998.

1. Documentation was not available at the time of the survey for the current inspection of the backflow preventor serving the Kidney Center.






.

A). Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.