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Tag No.: K0372
Based on observations made during the survey of the facility between the hours of 10:00 am and 3:00 pm, while accompanied by the CFO, Dir. Of Nursing, and the Dir. Of EMS it was observed that the facility was not in compliance with the following:
1 HOUR FIRE/SMOKE BARRIER WALL: The rated wall construction which separates the SMOKE COMPARTMENTS was incomplete and therefore is not in compliance.
Tag No.: K0906
Based on observations made during the survey of the facility between the hours of 10:00 am and 3:00 pm, while accompanied by the hospital's CFO, Dir. Of Nursing, and the Dir. Of EMS it was observed that the facility failed to provide racks, chains or other fastening means for the med gas cylinders located in the exterior "yard" location which were not secured as required.
Tag No.: K0911
Based on observations made during the survey of the facility between the hours of 10:00 am and 3:00 pm, while accompanied by the hospital's CFO, Dir. Of Nursing, and the Dir. Of EMS it was observed that the facility failed to show the surveyor the required 90-minute battery back-up lighting at the emergency generator location in accordance with NFPA99, 2012: 6.4.2.2.3(4). This lighting at the generator location shall be provided electrical power fed by the LIFE SAFETY BRANCH as well having the missing battery back-up.