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Based on observation and interview, it was determined the facility failed to maintain compliance with stair tower doors in two instances on one of four floors.

Findings Include:

Observation on November 5, 2012, revealed the following:

a) At 8:52 a.m., the stair tower door #1 on the third floor did not fully close and latch.
b) At 9:04 a.m., the stair tower door #2 on the third floor did not fully close and latch.

Interview with the facility administrator on November 5, 2012, at 2:00 p.m., confirmed the failure to comply with stair tower door requirements.

Based on observation and interview, it was determined the facility failed to maintain compliance with smoke barriers in three instances on two of four floors.

Findings Include:

Observation on November 5, 2012, revealed the following:

a) At 9:08 a.m., there were penetrations in the rated smoke wall above the ceiling in the third floor IT room.
b) At 9:30 a.m., there were penetrations above the ceiling in the rated smoke wall in the third floor west corridor near room 350-373.
c) At 9:43 a.m., there were penetrations and expandable foam in the rated smoke wall on the second floor west near room 232.

Interview with the facility administrator on November 5, 2012, at 2:00 p.m., confirmed the failure to comply with smoke barrier requirements.

Based on observation and interview, it was determined the facility failed to maintain compliance with hazardous area requirements in three instances on three of four floors.

Findings Include:

Observation on November 5, 2012, revealed the following:

a) At 9:22 a.m., the closure was broken on the door of the OR storage room on the third floor.
b) At 10:17 a.m., the door for the first floor Outpatient Registration storage room lacked an automatic door closer.
c) At 10:54 a.m., the door for the basement Medical Records Room 0010 does not close and latch tightly.

Interview with the facility administrator on November 5, 2012, at 2:00 p.m., confirmed the failure to comply with hazardous area requirements.

Based on observation and interview, it was determined the facility failed to maintain exit access in the corridor in one instance on one of four floors.

Findings Include:

Observation on November 5, 2012, revealed the following:

a) At 8:55 a.m., there was storage of scales, feeding chairs, and stationary chairs in the central corridor on the third floor near stair tower #1.

Interview with the facility administrator on November 5, 2012, at 2:00 p.m., confirmed the failure to comply with exit access requirements.

Based on observation and interview, it was determined the facility failed to maintain continuous illumination of the exit and directional signs one instance on one of four floors.

Findings Include:

Observation on November 5, 2012, revealed the following:

a) At 9:47 a.m., the exit sign above stairwell # 4 on the second floor was not illuminated.

Interview with the facility administrator on November 5, 2012, at 2:00 p.m., confirmed the failure to comply with exit and directional sign illumination compliance.

Based on observation and interview, it was determined the facility failed to maintain fire extinguisher compliance in one instance on one of four floors.

Findings Include:

Observation on November 5, 2012, revealed the following:

a) At 8:57 a.m., the fire extinguisher outside of room 302 lacks required six year maintenance.

Interview with the facility administrator on November 5, 2012, at 2:00 p.m., confirmed the failure to comply with fire extinguisher requirements.

Based on observation and interview, it was determined the facility failed to maintain compliance with the installed electrical standards in three instances on three of four floors.

Findings Include:

Observation on November 5, 2012, revealed the following:

a) At 9:24 a.m., an electrical box was without a cover in the third floor OR storage room.
b) At 10:17 a.m., an extension cord was being used in the first floor Doctors Lounge.
c) At 10:47 a.m., temporary lighting was being used in the basement Air Handler 1 room.

Interview with the facility administrator on November 5, 2012, at 2:00 p.m., confirmed the failure to comply with electrical requirements.

Based on observation and interview, it was determined the facility failed to maintain compliance with the installed Alcohol Based Hand Rub (ABHR) dispensers in three instances on one of four floors.

Findings Include:

Observation on November 5, 2012, revealed the following:

a) At 10:19 a.m., Alcohol Based Hand Rub (ABHR) was installed over carpet and an electrical outlet in the first floor Medical Records Office.
b) At 10:23 a.m., Alcohol Based Hand Rub (ABHR) was installed over carpet in the first floor Patient Accounting Office.
c) At 10:30 a.m., Alcohol Based Hand Rub (ABHR) was installed over carpet in the first floor Radiology room 153.

Interview with the facility administrator on November 5, 2012, at 2:00 p.m., confirmed the failure to comply with Alcohol Based Hand Rub (ABHR) requirements.

Based on observation and interview, it was determined the facility failed to maintain compliance with stair tower doors in two instances on one of four floors.

Findings Include:

Observation on November 5, 2012, revealed the following:

a) At 8:52 a.m., the stair tower door #1 on the third floor did not fully close and latch.
b) At 9:04 a.m., the stair tower door #2 on the third floor did not fully close and latch.

Interview with the facility administrator on November 5, 2012, at 2:00 p.m., confirmed the failure to comply with stair tower door requirements.

Based on observation and interview, it was determined the facility failed to maintain compliance with smoke barriers in three instances on two of four floors.

Findings Include:

Observation on November 5, 2012, revealed the following:

a) At 9:08 a.m., there were penetrations in the rated smoke wall above the ceiling in the third floor IT room.
b) At 9:30 a.m., there were penetrations above the ceiling in the rated smoke wall in the third floor west corridor near room 350-373.
c) At 9:43 a.m., there were penetrations and expandable foam in the rated smoke wall on the second floor west near room 232.

Interview with the facility administrator on November 5, 2012, at 2:00 p.m., confirmed the failure to comply with smoke barrier requirements.

Based on observation and interview, it was determined the facility failed to maintain compliance with hazardous area requirements in three instances on three of four floors.

Findings Include:

Observation on November 5, 2012, revealed the following:

a) At 9:22 a.m., the closure was broken on the door of the OR storage room on the third floor.
b) At 10:17 a.m., the door for the first floor Outpatient Registration storage room lacked an automatic door closer.
c) At 10:54 a.m., the door for the basement Medical Records Room 0010 does not close and latch tightly.

Interview with the facility administrator on November 5, 2012, at 2:00 p.m., confirmed the failure to comply with hazardous area requirements.

Based on observation and interview, it was determined the facility failed to maintain exit access in the corridor in one instance on one of four floors.

Findings Include:

Observation on November 5, 2012, revealed the following:

a) At 8:55 a.m., there was storage of scales, feeding chairs, and stationary chairs in the central corridor on the third floor near stair tower #1.

Interview with the facility administrator on November 5, 2012, at 2:00 p.m., confirmed the failure to comply with exit access requirements.

Based on observation and interview, it was determined the facility failed to maintain continuous illumination of the exit and directional signs one instance on one of four floors.

Findings Include:

Observation on November 5, 2012, revealed the following:

a) At 9:47 a.m., the exit sign above stairwell # 4 on the second floor was not illuminated.

Interview with the facility administrator on November 5, 2012, at 2:00 p.m., confirmed the failure to comply with exit and directional sign illumination compliance.

Based on observation and interview, it was determined the facility failed to maintain fire extinguisher compliance in one instance on one of four floors.

Findings Include:

Observation on November 5, 2012, revealed the following:

a) At 8:57 a.m., the fire extinguisher outside of room 302 lacks required six year maintenance.

Interview with the facility administrator on November 5, 2012, at 2:00 p.m., confirmed the failure to comply with fire extinguisher requirements.

Based on observation and interview, it was determined the facility failed to maintain compliance with the installed electrical standards in three instances on three of four floors.

Findings Include:

Observation on November 5, 2012, revealed the following:

a) At 9:24 a.m., an electrical box was without a cover in the third floor OR storage room.
b) At 10:17 a.m., an extension cord was being used in the first floor Doctors Lounge.
c) At 10:47 a.m., temporary lighting was being used in the basement Air Handler 1 room.

Interview with the facility administrator on November 5, 2012, at 2:00 p.m., confirmed the failure to comply with electrical requirements.