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Based on observation, on December 11, 2012 at approximately 8:30am onward, there are unsealed penetrations in the two hour fire barrier separating the EMS building from the hospital.

42 CFR 482.41(a)

Based on observation, on December 11, 2012 at approximately 8:30am onward, the building construction type is incomplete in the following area:

1. north corridor, near med-surg nurse's station, roof/ceiling assembly is not a minimum one hour rated; recessed light fixtures are not equipped with fire protective enclosures as necessary to protect open-web bar joist from fire exposure.

2. operating room suite - holes in suspended roof/ceiling assembly of hallway between operating room and old delivery room. The open-web steel bar joist are not protected from fire exposure.

3. operating room suite - lack of fire protective enclosures for recessed lights in suspended roof/ceiling assembly. Roof/ceiling assembly must meet design assembly specified by original construction documents

4. operating room suite - lack of listed fire damper assemblies in mechanical outlets/inlets in suspended roof/ceiling assembly. Roof/ceiling assembly must meet design assembly specified by original construction documents.


42 CFR 482.41(a)

Based on observation, on December 11, 2012 at approximately 8:30am onward, there is wood paneling used as a wainscot in the following rooms:

1. patient rooms 101, 102, 105,106, 108, 109, 110, 111, and 112.

2. radiology waiting room.

42 CFR 482.41(a)

Based on observation, on December 11, 2012 at approximately 8:30am onward, the one hour rated corridor wall is incomplete in the following area:

1. entry to palliative care suite - duct penetration is not equipped with fire damper. Damper must be installed in accordance with the manufacturer's installation instructions.

42 CFR 482.41(a)

Based on observation, on December 11, 2012 at approximately 8:30am onward, exit access doors in the following areas are noncompliant due to the following:

1. lack of latching hardware on door to office near med-surg nurse's station.

2. lack of minimum twenty-minute rated doors or equivalent rating in door openings to palliative care suite.

3. chapel - hollow core door of less than required fire rating in door opening.

4. door to chapel - hardware set is non-passage type from inside chapel.

42 CFR 482.41(a)

Based on observation, on December 11, 2012 at approximately 8:30am onward, hazardous areas in the following rooms are incomplete due to the following:

1. soiled utility/soiled linen room is not equipped with minimum c-labeled door and sprinkler(s) - located near med-surg nurse's station.

2. linen room #1 - formerly a patient room, is not equipped with a one hour enclosure and sprinkler(s).

3. generator room - lack of a complete two hour fire door assembly between maintenance office and fuel driven generator room.

42 CFR 482.41(a)

Based on observation, on December 11, 2012 at approximately 8:30am onward, there is a barrel-bolt latch used on the exit access door from the toilet between linen rooms #1, and #2. Doors may not be locked against egress from inside the room. Linen rooms, formerly patient rooms, are located on north corridor near med - surg nurse's station.

42 CFR 482.41(a)

Based on observation, on December 11, 2012 at approximately 8:30am onward, the exit access door between eight feet corridor and surgery waiting room is less than forty-one and a half inch opening width. The exit is required to prevent a dead-end corridor at entry to surgery suite. The existing level of life safety is reduced below standards required at time of area renovations; all other exit access doors used by patients in patient care areas are minimum 41.5 inch openings.

42 CFR 482.41(a)

Based on observation, on December 11, 2012 at approximately 8:30am onward, there is a single bulb light fixture located at the exit discharge near the Endoscopy procedure room.

42 CFR 482.41(a)

Based on observation, on December 11, 2012 at approximately 8:30am onward, the emergency lighting is incomplete in the following areas:

1. med-surg exit discharge - there is no emergency lighting provided from exit discharge to publicway.

2. palliative care suite - circuits supplying emergency power and normal power could not be distinguished by labeling of panelboard circuit directories. Life Safety branch lighting could not be identified.

3. exit discharge to publicway near Endoscopy procedure room - no emergency lighting to cover complete egress path.

42 CFR 482.41(a)

Based on observation, on December 11, 2012 at approximately 8:30am onward, the fire alarm system would not function on the alternate power(batteries) supply.

42 CFR 482.41(a)

Based on observation, on December 11, 2012 at approximately 8:30am onward, the means of egress is noncompliant due to the following:

1. door to office beside med-surg desk protrudes greater than seven inches into the corridor.

2. surgery waiting room and lobby - a minimum eight feet width is not maintained through lobby area.

42 CFR 482.41(a)

Based on observation, on December 11, 2012 at approximately 8:30am onward, there are oxygen cylinders stored in the respiratory office/storage room with combustible supplies and alcohol based hand sanitizer. The oxygen cylinders are not maintained a minimum twenty feet from combustibles(size of space will not allow this distance) - located off north corridor near med-surg nurse's station.

42 CFR 482.41(a)

Based on documentation, on December 11, 2012 at approximately 8:30am onward, the emergency generator is not exercised under load for thirty minutes per month.

42 CFR 482.41(a)

Based on observation, on December 11, 2012 at approximately 8:30am onward, the EES is incomplete due to the following:

1. medication preparation room near med-surg - lighting in room is not identified as connected to the critical branch of the essential electrical system.

2. visual indicators for normal power are not functioning on automatic transfer switches QB, and E - located in the generator room.

42 CFR 482.41(a)

Based on observation, on December 11, 2012 at approximately 8:30am onward, the facility is noncompliant with the National Electrical Code due to the following:

1. ground fault interrupter receptacle is not functioning properly in resident room 101 - located beside lavatory.

2. use of improperly listed multioutlet power tap in operating room - tap provided was not mounted to a mobile IV pole.

3. surgical light in operating room is not properly grounded by metal raceway terminating in an approved junction box; and connected to the base of fixture.

42 CFR 482.41(a)