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This tag not met as observed by this surveyor and the Facility Maintenance Director. It was observed that the two doors the PACU Soiled Utility room were blocked open by door wedges. Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area enclosure is held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the fire alarm system. Doors can be held open by magnetic hold open devices that are connected to the fire alarm system and when the fire alarm system is activated the magnet will release and allow the door to close and latch.

This tag not met as observed by this surveyor and the Facility Maintenance Director. It was observed that the Communications Equipment Room located in the In Patient Care area had several small openings in the back wall. These walls are to be made smoke tight.

This tag not met as observed by this surveyor and the Facility Maintenance Director. The main exit door for the building sticks on the floor rug when the door is put into manual operation. The door would only open about a quarter of the mormal opening.

This tag not met as observed by this surveyor and the Facility Maintenance Director. The current plan states the use of fire blankets and fire blankets are only available in one area of the building, the Facility Lab. Also the plan states that during a fire emergency staff and patients may have to be moved to another smoke area but the plan does not describe or define where the smoke areas are.

This tag not met as observed by this surveyor and the Facility Maintenance Director. it was observed when reviewing the Fire Evacuation Drill sheets that the required number of drills had not been accomplished during the past 12 month period. Drills were not conducted for the 3rd shift in the first two quarters of this period and drills not conducted for the 1st shift during the third quarter of this period. At least one drill per shift per quarter is required.

This tag not met as observed by this surveyor and the Facility Maintenance Director. It was observed that medical gas emergency shut off station located by the door leading out of the Patient Care area was being blocked when the door is opened. This door is normally kept in the open position therefore blocking the station. One of three things can be done to correct this; 1) Keep the door closed at all times (not recommended); 2) Move the station to a better area that would make the station accessible at all times; 3) Install signage that identifies the station when the door is in the open position. Indicate correction action.

The following additional deficiencies were found: 1) The emergency gas shutoff for the kitchen equipment that is located above the dropped ceiling needs to be relocated to an area below the dropped ceiling. Gas valves can not be located in an area that makes them unaccessible or in a confined space. 2) Two high pressure cylinders in the materials handling storage room were not properly secured. 3) Improper use of electrical extension cord in room CO6. The cord was used in leu of permanent wiring. 4) Storage on top of storage racks in the Radiology Files room were located in such a way that if the racks were moved the storage would block the sprinkler heads located above. 5) Fire extinguishers located in the corridors are recessed into the walls and do not have proper signage to identify the extinguisher location when down the corridor from the extinguisher. The requirement comes from NFPA 10, The location of fire extinguishers as described in shall be marked conspicuously.

This tag not met as observed by this surveyor and the Facility Maintenance Director. It was observed that the two doors the PACU Soiled Utility room were blocked open by door wedges. Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area enclosure is held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the fire alarm system. Doors can be held open by magnetic hold open devices that are connected to the fire alarm system and when the fire alarm system is activated the magnet will release and allow the door to close and latch.

This tag not met as observed by this surveyor and the Facility Maintenance Director. It was observed that the Communications Equipment Room located in the In Patient Care area had several small openings in the back wall. These walls are to be made smoke tight.

This tag not met as observed by this surveyor and the Facility Maintenance Director. The main exit door for the building sticks on the floor rug when the door is put into manual operation. The door would only open about a quarter of the mormal opening.

This tag not met as observed by this surveyor and the Facility Maintenance Director. The current plan states the use of fire blankets and fire blankets are only available in one area of the building, the Facility Lab. Also the plan states that during a fire emergency staff and patients may have to be moved to another smoke area but the plan does not describe or define where the smoke areas are.

This tag not met as observed by this surveyor and the Facility Maintenance Director. it was observed when reviewing the Fire Evacuation Drill sheets that the required number of drills had not been accomplished during the past 12 month period. Drills were not conducted for the 3rd shift in the first two quarters of this period and drills not conducted for the 1st shift during the third quarter of this period. At least one drill per shift per quarter is required.

This tag not met as observed by this surveyor and the Facility Maintenance Director. It was observed that medical gas emergency shut off station located by the door leading out of the Patient Care area was being blocked when the door is opened. This door is normally kept in the open position therefore blocking the station. One of three things can be done to correct this; 1) Keep the door closed at all times (not recommended); 2) Move the station to a better area that would make the station accessible at all times; 3) Install signage that identifies the station when the door is in the open position. Indicate correction action.

The following additional deficiencies were found: 1) The emergency gas shutoff for the kitchen equipment that is located above the dropped ceiling needs to be relocated to an area below the dropped ceiling. Gas valves can not be located in an area that makes them unaccessible or in a confined space. 2) Two high pressure cylinders in the materials handling storage room were not properly secured. 3) Improper use of electrical extension cord in room CO6. The cord was used in leu of permanent wiring. 4) Storage on top of storage racks in the Radiology Files room were located in such a way that if the racks were moved the storage would block the sprinkler heads located above. 5) Fire extinguishers located in the corridors are recessed into the walls and do not have proper signage to identify the extinguisher location when down the corridor from the extinguisher. The requirement comes from NFPA 10, The location of fire extinguishers as described in shall be marked conspicuously.