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Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 2nd floor housekeeping closet near room 258 has unsealed penetrations around the sprinkler heads
2. 3rd floor, In the old nurse locker room the is a unsealed penetration in the rated ceiling that is not properly sealed.
3. 3rd floor, In the old nurse locker room. At the time of the survey a fire damper in the HVAC duct penetrating the 2hr fire rated wall could not be verified as there was no access door installed at that location

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 3rd floor library this area is not sprinklered the paneling for this area was not verified to be Class A or Class B.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 3rd floor room 311A/B has door latching hardware missing not allowing the door on the corridor to latch to keep the door smoke tight.
2. 3rd floor room 309B has door latching hardware missing not allowing the door on the corridor to latch to keep the door smoke tight.
3. 3rd floor corridor doors to rooms 4 and 332 in the case management department do not have positive latching hardware installed.
4. 5th floor. The corridor door to room 410 does not close smoke tight. As there was a Gap at top of door not allowing the room to resist the passage of smoke.
5. 2nd floor Dialysis unit. The corridor door to the rooms 247, 246 and 244 in the Dialysis unit have and inactive leaf and did not close smoke tight if the inactive leaf bolt was not engaged.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 2nd floor. The corridor door to patient room 282 was blocked from closing.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 2nd floor B- wing data room, there are pipe penetrating the deck below and there were two of the pipes that were not sealed with approved fire stop materials.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 3rd floor in the old nurse locker room there the penetrations in the floor are not filled with approved fire stop materials

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 2nd floor bright leaf tower unsealed penetrations in the smoke wall at elevator 4 and 5 at the building joint on both sides of the building
2. 2nd floor bright leaf tower at the elevator 4 and 5 have unapproved foam fire stop insulation in the rated wall above the time clock

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 1st floor. The cross corridor doors leading for CT to MRI the doors have a door stops that keeps the door form closing installed a floor level hook .
2. 1st floor same day surgery both sets of cross corridor doors that defined the suite have a gap greater than 1/8th of an inch.
3. 3rd floor near room 324 when testing the fire door (DR#3-030) left leaf of the door scrubs the carpeted floor and did not close when released from magnet.
4. 1st floor, Emergency Waiting Room, cross corridor door located at the waiting room did not close tight at the bottom. There is gat at the bottom of the door greater than 1/8 of an inch.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 3rd floor room 318 is being used as storage and not have a door closure installed
2. 3rd floor sleep lab area near room 329 there is soiled linen stored in the exit egress corridor
3. 4th floor. Storage room located on the corridor is not 1hr fire rated construction or have sprinkler coverage.
4. Ground Floor, the corridor door to storage room G-046 was not self closing
5. Ground Floor, old boiler room, the corridor door to the old boiler room was not self closing.
6. Ground Floor, the corridor door to storage room G-047 was not self closing.
7. Ground Floor There are unsealed penetrations in the in the wall above the door on the inside of the room that was not sealed in order to maintain the required rating of the wall.
8. 3rd floor. The linen room storage corridor door was not self-closing

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. Clayton Facility. The corridor door to the clean linen room was found wedged open preventing the door from closing with one motion.
2. Clayton Facility. The storage room door located inside PACU leading to the oxygen storage room was not self closing.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Cancer Unit at Medical Mall, The mechanical room houses the gas fired water heater and that rooms door was not self closing

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 5th floor Bright Leaf Tower the older bathroom in the old patient rooms require two ranges of motion as there is a dead bolt that does not retract when tested.
2. 2nd floor door to room 200/ 211 has a hasp installed and if engaged would require more than two ranges of motions to exit the rooms.
3. 1st floor cross corridor doors leading from CT to MRI the door release switch at that area is a momentary switch and not a simple on and off switch
4. 5th floor soiled utility room has Dead bolt installed on the door,
5. 5th floor older bathroom doors, the door hardware does not have integrated pass-through locksets installed
6. 4th floor older bathroom doors, the door hardware does not have integrated pass-through locksets installed
7. 5th floor administration copy room has a Slide bolt locking device installed on the door not allowing single motion of the hand to enter the egress corridor.
8. 4th floor door to room 415 has a padlock installed on the door not allowing single motion of the hand to enter the egress corridor.
9. 2nd floor bright leaf tower dialysis center has a North Carolina Special locking magnets and plates installed on cross corridor doors ,but were not able to be tested during the survey as they were out of service
10. Stairwell " L " the Emergency Department tunnel landing at the top of the emergency department tunnel does not have protection in place to direct potential traffic exiting at that location from exiting down the stairs.
11. 1st floor Behavioral Health, Building is equipped with keyed exit doors and the facility is required to be sprinklered or covered with smoke detectors in all areas. The cloth storage closet located in the front hall is not equipped with a smoke detector.
12. 5th floor next to room 525E the Fire door at that location needs more than 15 pounds of force to get into the open position.
13. 5th Floor, Rooms 524 through 529 have chain latches install on the inside of the of the door frame that when latched would require more than one motion of the hand to exit the room
14. 4th floor, Conference room corridor door across from Human recourses waiting room is equipped with dead bolt that requires two motions of the hand to open when the lock is engaged.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. Stairwell " K " A door release override switch was not provided for the magnetically locked door at the stairwell for use in an emergency other than fire.
2. 2nd floor Stairwell " O " . A door release override switch was not provided for the magnetically locked door at the stairwell for use in an emergency other than fire.
3. Ground floor loading dock the Exit egress at the loading dock is not clearly identified so not to lead persons exiting towards the loading and unloading area.
4. Ground floor Cross corridor doors next to nursing supervisor office has North Carolina Special Locking device installed and not in service at time of the survey. The device must be in use or disabled in some way.
5. Ground floor food service older freezer and cooler door release mechanism is not visible in all levels of light at the beverage storage area across the corridor from the dietary department.
6. 4th Floor Room 414 has a hasp installed and if engaged would not allow for a one motion of the hand to exit that room.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 1st floor, the interior courtyard located at building #1 is not equipped with exit signage

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. Ground floor, Exit light at exit discharge door from 2 East stairwell was not illuminated during the survey.
2. 1st floor, North Emergency Entrance, emergency discharge lighting on the emergency circuit was not provided for at the walk way past that exit door discharge.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Clayton Facility. The exit path to the public way from the side and rear of the building was not provided with sufficient exit discharge path illumination connected to emergency. Illumination of means of egress, including exit discharge, shall be arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 2nd floor, exit directional signage is incomplete at cross corridor door leading to Dialysis Unit.
2. 1st floor, the exit directional sign located at the cross corridor doors leading to the corridor in front of Behavioral Health was not verified to be connected to an emergency circuit emergency.
3. Ground Floor, and exit directional signage is incomplete leading from the elevator and to the linen room
4. 1st floor cross corridor doors leading from CT to MRI. The exit directional signage leading to the MRI area from the CT area is misleading as that corridor is not a required exit.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 1st Floor the cross corridor doors located in at x-ray in the north emergency hall did not close on activation of fire alarm system with a person in the vicinity of the door sensor

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Smoke curtain at Food Service between the AED and the fire extinguisher did not release & reengage with fire alarm activation when an obstacle was placed under the fire curtain

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 2nd floor. Smoke duct detector M1-45 was not clean and maintained in good condition

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 2nd floor staff shower room in the ICU has sprinkler head blocked by shower curtain that does not have mesh on the top
2. it was determined with staff interviews that there were no sprinkler head at the top the # 83 and #49 dumb waiters that are no longer in service

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. Ground Floor Medical records area had dust and lint on the heat sensitive elements of the sprinkler head in the stack room.
2. Ground floor Food Service area the sprinkler head has dust/grease on the heat sensitive element of the sprinkler head, above the dietary fryer location.
3. The shower curtains in the patient room showers are not provided with a 18 inch mesh tops in order to allow for proper sprinkler coverage.
4. Ground floor food service, there are two light fixtures blocking sprinkler heads in refrigerator number 5.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 1st floor Women ' s pavilion-mechanical room does not have an access door for smoke damper in the rated wall at that location.
2. 4th floor, in the corridor outside Human Recourses waiting room, the access door to the smoke duct detector and smoke damper was blocked by a light fixture and was not easily accessible
3. 3rd floor, and access door was not provided for to the smoke duct detector located in the corridor outside Education Storage.
4. 2nd floor Soiled Utility Room Dialysis Unit. An access door was not provided for the smoke duct detector located in the unit.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Ground floor food service, the hood suppression system nozzles are not pointing at the equipment it is designed to protect.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 4th floor Linen Chute on 4th floor opens onto the corridor was not self closing.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 2nd floor storage closet near room 207 it was determined that the facility had a storage closet near room 207 opened into the corridor, this door did not open 180 degrees flat to the corridor wall nor had a door closure installed to automatically keep the door closed after being opened.
2. 5th floor it was determined that the facility had a bathroom in the administrative area near room 508 that opened into the corridor, this door did not open 180 degrees flat to the corridor wall nor had a door closure installed to automatically keep the door closed after being opened.
3. 5th it was determined that the facility had a ladies toilet door near elevator # 2 that opened into the corridor, this door did not open 180 degrees flat to the corridor wall nor had a door closure installed to automatically keep the door closed after being opened.
4. Ground floor Environmental Services corridor next to elevator # 3 has large clean linen cart stored in exit egress corridor
5. 2nd floor pharmacy / Rehab area there is IT equipment rack stored in the corridor without direct visual supervision from the regularly manned station .
6. 5th Floor, it was determined that the facility had a bathroom next to room 508 that opened into the corridor, this door did not open 180 degrees flat to the corridor wall nor had a door closure installed to automatically keep the door closed after being opened.
7. 4th floor North Hall Human Resources corridor it was determined that the facility had a soiled linen room door that opened into the corridor, this door did not open 180 degrees flat to the corridor wall nor had a door closure installed to automatically keep the door closed after being opened.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. Ground floor Food service corridor has items store in the egress corridor that is currently not in use. This corridor is not currently included in the designated suite for that area.
2. The facility had storage in the corridor in front of the cross corridor door located near the soiled linen storage area that would prevent the cross corridors from closing

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Cancer Unit Medical Mall, the rear exit egress corridor was not maintained clear maintained and obstructed as there was storage items left in the egress corridor during the survey.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 2nd floor patient rehab there was no signage noting oxygen being stored in that space.
2. 3rd floor room 329 (sleep lab storage), there was no signage noting oxygen being stored in that space.
3. 3rd floor room 329 distances between the stored oxygen and combustible storage in the room did not meet the requirements for a sprinklered building.
4. Main oxygen cylinder storage area, The Main medical gas storage is not individually secured.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 1st floor Operating Room Suite, the clean utility near OR room 5- oxygen cylinders at that location did not meet the requirements for separation form combustible material a sprinklered building.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Oxygen farm, the Medical Mall Wound Care oxygen storage cylinders outside are not protected with:

1. Over head protection for the cylinder valves from extremes of weather.
2. Ground protection under the cylinders from extremes of weather.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Clayton Facility. In the bulk oxygen storage room, oxygen cylinders were found gang chained together and not individually secured.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Clayton Facility The relative humidity in operating room #1 and #2 was not maintained equal to or greater than 35%.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 2nd Floor, The smoke damper located in the soiled utility room in the Dialysis unit did not close upon activation of fire alarm system

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Clayton Facility. The generator annunciator panel did not show that the generator was currently supplying the load when power was transferred from normal to emergency power.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 5th floor Bright Leaf Tower administration are older bath tub room has exposed bulbs on the light fixture.
2. 1st Floor endoscopy rooms 2 and 3 has temporary power used as permanent power for the endoscopy camera Machines
3. 4th floor. Human resources break room is utilizing a power strip in place of permanent wiring for the microwave and coffee pot.
4. 3rd floor 3-B. A power strip was used in place of permanent wiring for the medication refrigerator on 3B
5. 2nd floor, medication refrigerator in PCU B-wing was not connected on emergency power.
6. 3rd floor inside the old nurse ' s locker room 320 there is an exposed light bulb without a lens cover in room

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 3rd floor nurses station has ABHR in the vicinity of an ignition source
2. 2nd floor Bright leaf tower inside the dialysis soiled utility room there was an ABHR above in ignition source. (Light Switch)

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 1st Floor Labor and delivery - delivery room # 5 has an ABSH installed over or adjacent to an ignition source. light switch.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 2nd floor housekeeping closet near room 258 has unsealed penetrations around the sprinkler heads
2. 3rd floor, In the old nurse locker room the is a unsealed penetration in the rated ceiling that is not properly sealed.
3. 3rd floor, In the old nurse locker room. At the time of the survey a fire damper in the HVAC duct penetrating the 2hr fire rated wall could not be verified as there was no access door installed at that location

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 3rd floor library this area is not sprinklered the paneling for this area was not verified to be Class A or Class B.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 3rd floor room 311A/B has door latching hardware missing not allowing the door on the corridor to latch to keep the door smoke tight.
2. 3rd floor room 309B has door latching hardware missing not allowing the door on the corridor to latch to keep the door smoke tight.
3. 3rd floor corridor doors to rooms 4 and 332 in the case management department do not have positive latching hardware installed.
4. 5th floor. The corridor door to room 410 does not close smoke tight. As there was a Gap at top of door not allowing the room to resist the passage of smoke.
5. 2nd floor Dialysis unit. The corridor door to the rooms 247, 246 and 244 in the Dialysis unit have and inactive leaf and did not close smoke tight if the inactive leaf bolt was not engaged.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 2nd floor. The corridor door to patient room 282 was blocked from closing.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 2nd floor B- wing data room, there are pipe penetrating the deck below and there were two of the pipes that were not sealed with approved fire stop materials.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 3rd floor in the old nurse locker room there the penetrations in the floor are not filled with approved fire stop materials

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 2nd floor bright leaf tower unsealed penetrations in the smoke wall at elevator 4 and 5 at the building joint on both sides of the building
2. 2nd floor bright leaf tower at the elevator 4 and 5 have unapproved foam fire stop insulation in the rated wall above the time clock

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 1st floor. The cross corridor doors leading for CT to MRI the doors have a door stops that keeps the door form closing installed a floor level hook .
2. 1st floor same day surgery both sets of cross corridor doors that defined the suite have a gap greater than 1/8th of an inch.
3. 3rd floor near room 324 when testing the fire door (DR#3-030) left leaf of the door scrubs the carpeted floor and did not close when released from magnet.
4. 1st floor, Emergency Waiting Room, cross corridor door located at the waiting room did not close tight at the bottom. There is gat at the bottom of the door greater than 1/8 of an inch.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 3rd floor room 318 is being used as storage and not have a door closure installed
2. 3rd floor sleep lab area near room 329 there is soiled linen stored in the exit egress corridor
3. 4th floor. Storage room located on the corridor is not 1hr fire rated construction or have sprinkler coverage.
4. Ground Floor, the corridor door to storage room G-046 was not self closing
5. Ground Floor, old boiler room, the corridor door to the old boiler room was not self closing.
6. Ground Floor, the corridor door to storage room G-047 was not self closing.
7. Ground Floor There are unsealed penetrations in the in the wall above the door on the inside of the room that was not sealed in order to maintain the required rating of the wall.
8. 3rd floor. The linen room storage corridor door was not self-closing

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. Clayton Facility. The corridor door to the clean linen room was found wedged open preventing the door from closing with one motion.
2. Clayton Facility. The storage room door located inside PACU leading to the oxygen storage room was not self closing.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Cancer Unit at Medical Mall, The mechanical room houses the gas fired water heater and that rooms door was not self closing

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 5th floor Bright Leaf Tower the older bathroom in the old patient rooms require two ranges of motion as there is a dead bolt that does not retract when tested.
2. 2nd floor door to room 200/ 211 has a hasp installed and if engaged would require more than two ranges of motions to exit the rooms.
3. 1st floor cross corridor doors leading from CT to MRI the door release switch at that area is a momentary switch and not a simple on and off switch
4. 5th floor soiled utility room has Dead bolt installed on the door,
5. 5th floor older bathroom doors, the door hardware does not have integrated pass-through locksets installed
6. 4th floor older bathroom doors, the door hardware does not have integrated pass-through locksets installed
7. 5th floor administration copy room has a Slide bolt locking device installed on the door not allowing single motion of the hand to enter the egress corridor.
8. 4th floor door to room 415 has a padlock installed on the door not allowing single motion of the hand to enter the egress corridor.
9. 2nd floor bright leaf tower dialysis center has a North Carolina Special locking magnets and plates installed on cross corridor doors ,but were not able to be tested during the survey as they were out of service
10. Stairwell " L " the Emergency Department tunnel landing at the top of the emergency department tunnel does not have protection in place to direct potential traffic exiting at that location from exiting down the stairs.
11. 1st floor Behavioral Health, Building is equipped with keyed exit doors and the facility is required to be sprinklered or covered with smoke detectors in all areas. The cloth storage closet located in the front hall is not equipped with a smoke detector.
12. 5th floor next to room 525E the Fire door at that location needs more than 15 pounds of force to get into the open position.
13. 5th Floor, Rooms 524 through 529 have chain latches install on the inside of the of the door frame that when latched would require more than one motion of the hand to exit the room
14. 4th floor, Conference room corridor door across from Human recourses waiting room is equipped with dead bolt that requires two motions of the hand to open when the lock is engaged.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. Stairwell " K " A door release override switch was not provided for the magnetically locked door at the stairwell for use in an emergency other than fire.
2. 2nd floor Stairwell " O " . A door release override switch was not provided for the magnetically locked door at the stairwell for use in an emergency other than fire.
3. Ground floor loading dock the Exit egress at the loading dock is not clearly identified so not to lead persons exiting towards the loading and unloading area.
4. Ground floor Cross corridor doors next to nursing supervisor office has North Carolina Special Locking device installed and not in service at time of the survey. The device must be in use or disabled in some way.
5. Ground floor food service older freezer and cooler door release mechanism is not visible in all levels of light at the beverage storage area across the corridor from the dietary department.
6. 4th Floor Room 414 has a hasp installed and if engaged would not allow for a one motion of the hand to exit that room.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 1st floor, the interior courtyard located at building #1 is not equipped with exit signage

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. Ground floor, Exit light at exit discharge door from 2 East stairwell was not illuminated during the survey.
2. 1st floor, North Emergency Entrance, emergency discharge lighting on the emergency circuit was not provided for at the walk way past that exit door discharge.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Clayton Facility. The exit path to the public way from the side and rear of the building was not provided with sufficient exit discharge path illumination connected to emergency. Illumination of means of egress, including exit discharge, shall be arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 2nd floor, exit directional signage is incomplete at cross corridor door leading to Dialysis Unit.
2. 1st floor, the exit directional sign located at the cross corridor doors leading to the corridor in front of Behavioral Health was not verified to be connected to an emergency circuit emergency.
3. Ground Floor, and exit directional signage is incomplete leading from the elevator and to the linen room
4. 1st floor cross corridor doors leading from CT to MRI. The exit directional signage leading to the MRI area from the CT area is misleading as that corridor is not a required exit.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 1st Floor the cross corridor doors located in at x-ray in the north emergency hall did not close on activation of fire alarm system with a person in the vicinity of the door sensor

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Smoke curtain at Food Service between the AED and the fire extinguisher did not release & reengage with fire alarm activation when an obstacle was placed under the fire curtain

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 2nd floor. Smoke duct detector M1-45 was not clean and maintained in good condition

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 2nd floor staff shower room in the ICU has sprinkler head blocked by shower curtain that does not have mesh on the top
2. it was determined with staff interviews that there were no sprinkler head at the top the # 83 and #49 dumb waiters that are no longer in service

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. Ground Floor Medical records area had dust and lint on the heat sensitive elements of the sprinkler head in the stack room.
2. Ground floor Food Service area the sprinkler head has dust/grease on the heat sensitive element of the sprinkler head, above the dietary fryer location.
3. The shower curtains in the patient room showers are not provided with a 18 inch mesh tops in order to allow for proper sprinkler coverage.
4. Ground floor food service, there are two light fixtures blocking sprinkler heads in refrigerator number 5.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 1st floor Women ' s pavilion-mechanical room does not have an access door for smoke damper in the rated wall at that location.
2. 4th floor, in the corridor outside Human Recourses waiting room, the access door to the smoke duct detector and smoke damper was blocked by a light fixture and was not easily accessible
3. 3rd floor, and access door was not provided for to the smoke duct detector located in the corridor outside Education Storage.
4. 2nd floor Soiled Utility Room Dialysis Unit. An access door was not provided for the smoke duct detector located in the unit.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Ground floor food service, the hood suppression system nozzles are not pointing at the equipment it is designed to protect.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 4th floor Linen Chute on 4th floor opens onto the corridor was not self closing.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 2nd floor storage closet near room 207 it was determined that the facility had a storage closet near room 207 opened into the corridor, this door did not open 180 degrees flat to the corridor wall nor had a door closure installed to automatically keep the door closed after being opened.
2. 5th floor it was determined that the facility had a bathroom in the administrative area near room 508 that opened into the corridor, this door did not open 180 degrees flat to the corridor wall nor had a door closure installed to automatically keep the door closed after being opened.
3. 5th it was determined that the facility had a ladies toilet door near elevator # 2 that opened into the corridor, this door did not open 180 degrees flat to the corridor wall nor had a door closure installed to automatically keep the door closed after being opened.
4. Ground floor Environmental Services corridor next to elevator # 3 has large clean linen cart stored in exit egress corridor
5. 2nd floor pharmacy / Rehab area there is IT equipment rack stored in the corridor without direct visual supervision from the regularly manned station .
6. 5th Floor, it was determined that the facility had a bathroom next to room 508 that opened into the corridor, this door did not open 180 degrees flat to the corridor wall nor had a door closure installed to automatically keep the door closed after being opened.
7. 4th floor North Hall Human Resources corridor it was determined that the facility had a soiled linen room door that opened into the corridor, this door did not open 180 degrees flat to the corridor wall nor had a door closure installed to automatically keep the door closed after being opened.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. Ground floor Food service corridor has items store in the egress corridor that is currently not in use. This corridor is not currently included in the designated suite for that area.
2. The facility had storage in the corridor in front of the cross corridor door located near the soiled linen storage area that would prevent the cross corridors from closing

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Cancer Unit Medical Mall, the rear exit egress corridor was not maintained clear maintained and obstructed as there was storage items left in the egress corridor during the survey.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 2nd floor patient rehab there was no signage noting oxygen being stored in that space.
2. 3rd floor room 329 (sleep lab storage), there was no signage noting oxygen being stored in that space.
3. 3rd floor room 329 distances between the stored oxygen and combustible storage in the room did not meet the requirements for a sprinklered building.
4. Main oxygen cylinder storage area, The Main medical gas storage is not individually secured.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 1st floor Operating Room Suite, the clean utility near OR room 5- oxygen cylinders at that location did not meet the requirements for separation form combustible material a sprinklered building.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Oxygen farm, the Medical Mall Wound Care oxygen storage cylinders outside are not protected with:

1. Over head protection for the cylinder valves from extremes of weather.
2. Ground protection under the cylinders from extremes of weather.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Clayton Facility. In the bulk oxygen storage room, oxygen cylinders were found gang chained together and not individually secured.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Clayton Facility The relative humidity in operating room #1 and #2 was not maintained equal to or greater than 35%.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 2nd Floor, The smoke damper located in the soiled utility room in the Dialysis unit did not close upon activation of fire alarm system

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Clayton Facility. The generator annunciator panel did not show that the generator was currently supplying the load when power was transferred from normal to emergency power.

Based on the observations and staff interviews on 1/7/2014 approximately 10:00 AM onward till 1/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:

1. 5th floor Bright Leaf Tower administration are older bath tub room has exposed bulbs on the light fixture.
2. 1st Floor endoscopy rooms 2 and 3 has temporary power used as permanent power for the endoscopy camera Machines
3. 4th floor. Human resources break room is utilizing a power strip in place of permanent wiring for the microwave and coffee pot.
4. 3rd floor 3-B. A power strip was used in place of permanent wiring for the medication refrigerator on 3B
5. 2nd floor, medication refrigerator in PCU B-wing was not connected on emergency power.
6. 3rd floor inside the old nurse ' s locker room 320 there is an exposed light bulb without a lens cover in room