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Based on observation, on June 2, 2010 at approximately 5:00am onward, there are gaps greater than one eight of an inch between the meeting edges of exit access doors serving the recovery suite.(located in the maternity center)

Based on observation, on June 2, 2010 at approximately 5:00am onward, there are deadbolt latches on exit access doors in the third floor storage rooms - located in circular tower section.

Note: Additional latching devices were removed during survey - doors did not require greater than a single hand motion.

Based on observation, on June 2, 2010 at approximately 5:00am onward, the fire safety policies and procedures are incomplete due to the following:

a. there are no posted evacuation signs for the means of egress serving operating rooms 1 - 4.

b. fire safety procedures did not address the location and use of air handler emergency shutdown switches during fire emergencies.

Based on observation, on June 2, 2010 at approximately 5:00am onward, there is no sprinkler system coverage in the following areas:

a. manager's closet - located in PACU/ICU.

b. shower stall in men's dressing room - OR Suite.

Based on observation, on June 2, 2010 at approximately 5:00am onward, the following sprinkler system components were noncompliant:

a. heat box containing main sprinkler valves and backflow preventer - heater and emergency receptacle did not function during initial test. Heater circuit in emergency electrical panelboard was not identified as required by the National Electrical Code. Heater and receptacle were corrected prior to completion of survey.

b. gauges located in fire pump main are not listed for fire protection service.

Based on observation, on June 2, 2010 at approximately 5:00am onward, the following mechanical system components are incomplete:


a. lack of emergency shutdown switch at a supervised station - air handling unit serving operating rooms 1 - 4.

Based on observation, on June 1, 2010 at approximately 2:30pm onward, the means of egress is obstructed due to the following:

a. doors to clean linen storage closet protrude greater than seven inches into the required corridor width in the fully open position.(fifth floor cylindrical tower section)

Based on observation, on June 2, 2010 at approximately 5:00am onward, location of medical gas system zone valves could not be verified for operating room suite containing rooms #1 - #4. Engineered drawings failed to provide correct location of valves. Alarm signals could not be verified for a pressure differential of plus or minus twenty percent of operating pressure.

Based on observation, on June 2, 2010 at approximately 5:00am onward, the following electrical system components are noncompliant:

a. broken lamp test switch for generator annunciator panel serving generators #1, and #2.

Note: Switch was immediately corrected by facilities management during survey.

b. delayed egress locks serving maternity center did not release during loss of power - located near manager's office.

Note: Improperly labeled circuit breaker was corrected during survey - lock was verified to release with loss of power.

Based on observation, on June 2, 2010 at approximately 5:00am onward, there are gaps greater than one eight of an inch between the meeting edges of exit access doors serving the recovery suite.(located in the maternity center)

Based on observation, on June 2, 2010 at approximately 5:00am onward, there are deadbolt latches on exit access doors in the third floor storage rooms - located in circular tower section.

Note: Additional latching devices were removed during survey - doors did not require greater than a single hand motion.

Based on observation, on June 2, 2010 at approximately 5:00am onward, the fire safety policies and procedures are incomplete due to the following:

a. there are no posted evacuation signs for the means of egress serving operating rooms 1 - 4.

b. fire safety procedures did not address the location and use of air handler emergency shutdown switches during fire emergencies.

Based on observation, on June 2, 2010 at approximately 5:00am onward, there is no sprinkler system coverage in the following areas:

a. manager's closet - located in PACU/ICU.

b. shower stall in men's dressing room - OR Suite.

Based on observation, on June 2, 2010 at approximately 5:00am onward, the following sprinkler system components were noncompliant:

a. heat box containing main sprinkler valves and backflow preventer - heater and emergency receptacle did not function during initial test. Heater circuit in emergency electrical panelboard was not identified as required by the National Electrical Code. Heater and receptacle were corrected prior to completion of survey.

b. gauges located in fire pump main are not listed for fire protection service.

Based on observation, on June 2, 2010 at approximately 5:00am onward, the following mechanical system components are incomplete:


a. lack of emergency shutdown switch at a supervised station - air handling unit serving operating rooms 1 - 4.

Based on observation, on June 1, 2010 at approximately 2:30pm onward, the means of egress is obstructed due to the following:

a. doors to clean linen storage closet protrude greater than seven inches into the required corridor width in the fully open position.(fifth floor cylindrical tower section)

Based on observation, on June 2, 2010 at approximately 5:00am onward, location of medical gas system zone valves could not be verified for operating room suite containing rooms #1 - #4. Engineered drawings failed to provide correct location of valves. Alarm signals could not be verified for a pressure differential of plus or minus twenty percent of operating pressure.

Based on observation, on June 2, 2010 at approximately 5:00am onward, the following electrical system components are noncompliant:

a. broken lamp test switch for generator annunciator panel serving generators #1, and #2.

Note: Switch was immediately corrected by facilities management during survey.

b. delayed egress locks serving maternity center did not release during loss of power - located near manager's office.

Note: Improperly labeled circuit breaker was corrected during survey - lock was verified to release with loss of power.