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A. Based on random observations during the survey walk through, areas open to corridors are observed which pose a degree of hazard greater than that normal to the general occupancy which does not comply with 19.3.2.1.

1. a. Corrected 09/16/2010.
b. Corrected 09/16/2010.
2. Corrected 09/16/2010.

3. Location observed: Kelly's Medical Supply located in the Main Hospital exit access corridor adjacent to the Main Lobby and the Gift Shop. Surveyor observed a nonseparated hazardous area deemed as storage by the Authority Having Jurisdiction. Further this space is leased and does not maintain the same hours as the Hospital. This area contains numerous combustible materials ie. foam bed supplies, numerous combustibles wrapped in plastic and cardboard boxes lined along three walls of shelves. The adjacent areas are not separated or adequately protected due to the following:

Update 07/06/11 : Interim Life Safety measures are in place, additional sprinkler protection and additional smoke detectors are installed. We are unable to clear this tag until construction for the new area is completed.

B. Surveyor observed a place of assembly which is open to an area which poses a degree of hazard greater than that normal to the general occupancy. This does not comply with 13.3.2.1.3 (2) for areas of assembly.

1. Location observed: First Floor 1953 building Kitchen (greater than 500 square feet - deemed hazardous due to the amount of combustibles being stored) which is open to the Cafeteria (area of assembly). Hospital staff were unable to indicate the exact location of the 1-hour fire resistant barrier(refer to C. 1. this K-Tag). The Cafeteria is provided with sprinkler protection, however, the Kitchen did not appear to be sprinkler protected.


C. Surveyor observed a non sprinkler protected kitchen (greater than 500 square feet) which is open to the means of egress due to a door which was held open by a door wedge which does not comply with 8.4.1.3 for self closing, 3/4 hour fire rated door in a barrier (Facility provided Life Safety Drawings indicate this wall as a 1-hour barrier).

1. Location observed: First Floor 1953 building Corridor dooor for Kitchen. Based on random observations during the survey walk through, areas which pose a degree of hazard greater than that normal to the business occupancy does not comply with 39.3.2.1 and 8.4.1.1.


D. 1. a. Corrected 09/16/2010.
b. Corrected 09/16/2010.
c. Corrected 09/16/2010.

E. 1. Corrected 09/16/2010.
2. Corrected 09/16/2010.
F. Corrected 09/16/2010.
G. Corrected 04/19/2012.

A. Corrected 9/16/2010.
B. Separation of medical gas zone control valves from supplied outlets and inlets in the emergency department. (NFPA 99, 1999, 4-3.1.2.3 (d)



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A. A701 CFR 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured.
In particular spaces containing storage such as the closets for the gift shop located along the east/west exit corridor of the 1994 Building. First indication was that the gift shop manager had the only keys and that individual was not available to provide access. Engineering eventually provided a key after considerable time had passed. Should an incident within the stored areas occur, the time delay in responding jeopardizes the safety of patients, staff and visitors. The storage closets fire protection is compromised by stored items on shelves which are closer than 18 inches the ceiling (refer to K-Tag 056 item E).



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B. Interim Life Safety Measures: 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.





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