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42 CFR 482.41(a)

Based on observations, on May 10, 2016 at approximately 10:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

Construction renovation area, near room U493, creates an excessive dead-end corridor travel distance - dead end corridor exceeds thirty feet.

NFPA 101, 19.2.5.10


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 May 10, 2016 at approximately 10:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is excessive positive latching hardware on door to room U439 - hardware is non-passage type from inside room. Door latching hardware shall not require greater than a single hand motion to exit room.

NFPA 101, 19.2.1, 7.1, 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 May 10, 2016 at approximately 10:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is no exit signs visible from area between horizontal sliding door and cross corridor fire barrier doors - located in front of entry to Endoscopy Unit on fourth floor.

NFPA 101, 19.2.10.1, 7.10.2


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.

42 CFR 482.41(a)

Based on observations, on May 10, 2016 at approximately 10:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

There is no continuously sounding audible signal with sprinkler control valve in the closed position - located in fourth floor stairway riser.

NFPA 101, 9.7.2.1


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 May 10, 2016 at approximately 10:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is no sprinkler provided in corridor area between temporary construction barrier and existing smoke barrier doors - located near room U489.

2. There is no sprinkler provided in stair vestibule near stair S.10 - area is bound by four walls.

NFPA 101, 19.3.5..1, 19.7.6, 9.7.5, 4.6.12, NFPA 13, NFPA 25


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 May 10, 2016 at approximately 10:00 AM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There are cabinet assemblies obstructing corridor width at area between cross corridor fire doors and pharmacy area on the fourth floor. Doors to cabinets are not self-closing and protrude greater than seven inches into required corridor width in the fully open position - entire unit protrudes greater than four and a half inch from corridor wall.

2. Magnetic hold-open device is mounted on floor area of means of egress - located beside cross corridor fire door assembly near fourth floor Endoscopy Unit entrance.

NFPA 101, 19.2.1, 7.1.10.1


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.