HospitalInspections.org

42 CFR 482.41(a)

Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The soiled linen room near patient room 112 in the behavioral health area has an unsealed penetration in the rated ceiling above the ceiling tile.

2. The social workers office near patient room 112 in the behavioral health area has an unsealed penetration in the rated ceiling above the ceiling tile near the light fixture.

3. The soiled utility room has an unsealed penetration in the wall in the back of the room past the soffit in the ICU unit.

NFPA 101, 19.1.6.2; 8.2.3.2.4.2*

This deficiency affected one of two smoke compartments in each of the areas mentioned.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Corridor wall is not complete to the underside of the deck - located above ceiling near MRI-Suite on first floor.

2. Pass-through window at first floor medical records area is not smoke tight; and is not designed to maintain required fire resistance rating of corridor wall and openings in buildings not equipped with a complete automatic sprinkler system.

3. Sheet metal cover, with barrel bolt latches, is not designed to maintain required fire resistance rating of corridor wall penetration in pharmacy pass-through window. Pharmacy is located on first floor.

NFPA 101, 19.3.6.1, 19.3.6.2, 19.3.6.4, 19.3.6.5

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Door to social work office is equipped with a roller latch - room is located in the Behavioral Health Unit near room 122.

2. Positive latching hardware is not functioning on door to dayroom - located beside room 123 in the Behavioral Health Unit.

NFPA 101, 19.3.6.3

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Cross corridor doors are equipped with electromagnetic locking device; the locking arrangement is not equipped with delayed feature and the facility is not equipped with a complete automatic sprinkler system or a complete detection system. Lock is located on cross corridor door between second floor elevator and OR Suite nurse's station.

NFPA 101, 19.2.4.1, 19.2.4.2, 7.2.1.6.1

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Exit discharge doors to loading dock area require greater than a single hand motion to open a pair of doors to achieve required exit width - one door leaf is less than thirty-two inches width - doors are located on the first floor near materials management.

NFPA 101, 19.2.3.5, 7.2.1.5.4

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Cross corridor door area is not equipped with exit sign at time of survey. Doors are located between second floor elevator and OR Suite nurse's station.

NFPA 101, 19.2.10.1

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

The strobe light is not functioning for the audible/visual signaling device in the materials management area - located on the first floor.

NFPA 101, 9.6.1.7, 9.6.1.4, NFPA 72

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The emergency exit discharge lighting serving Behavioral Health, Outpatient Pain Center, and area near green canopy are not equipped with lighting connected to the Life Safety Branch of the essential electrical system.

2. Remote emergency stop switch for generator is mounted to the generator exterior housing and not located remote from generator.

3. There is no low fuel indicator to monitor fuel level in main fuel tank for the emergency generator. Generator annunciator shall function when the main fuel storage tank contains less than a 3-hour operating supply.(NFPA 99, Section 3-4.1.1.15)

NFPA 101, NFPA 99, Sections 3-4.2.2.2, 3-5.2.2



This deficiency potentially affects all smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Electrical junction box with wires and terminal connectors is not equipped with a junction box cover - box is located on exterior wall of outpatient pain center exit discharge.

2. Room air conditioners in the following areas are not equipped with single use circuit and receptacles in accordance with manufacturer's listing:

a. LTAC Administration Offices

3. An electrical junction box with wires and terminal connectors is not equipped with a junction box cover. The box is located in the behavioral health unit above the ceiling above the ceiling tile near the staff lounge.

NFPA 101, 19.9.1, 9.1.2

This deficiency affected one of two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.