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It was observed that the facility is hanging non rated Isolation boxes on patient room doors. The boxes do not meet flame spread requirements. The boxes are made of ABS plastic and do not have a flame spread rating.

This tag not met as observed by this surveyor and the Facilities Maintenance Director. It was observed that the fire doors located near Med Surge and the main entrance lobby had several openings above the doors that were not properly sealed.

It was also observed that the fire door locate near Med Surge did not close and latch properly.

It was also observed that patient room doors #202, 203 & 205 did not close and or latch properly as required to maintain a smoke tight seal.

This tag not met as observed by this surveyor and the Facilities Maintenance Director. It was observed that above the fire doors located outside of X-ray and the doors leading into the patient rooms area have penetrations that are required to be sealed.

This tag not met as observed by this surveyor and the Facilities Maintenance Director. It was observed that the Soiled Utility room located outside of the ER Department does not have the required closure device as required.

This tag not met as observed by this surveyor and the Facilities Maintenance Director. It was observed that in the Emergency Department corridor there were 2 computers on wheels that were being stored in the corridor with chairs in front of them and they were reducing the corridor width.

This tag not met as observed by this surveyor and the Facilities Maintenance Director. It was observed that the PA On Call room on the first floor did not have the required smoke detection. The detector can be a local alarm only detector.

This tag not met as observed by this surveyor and the Facilities Maintenance Director. It was observed that in the OR Clean Utility room, storage was to close to the sprinkler head.

It was also observed that in the Medical Records room a sprinkler head located in the ceiling was missing an escutcheon ring.

This tag not met as observed by this surveyor and the Facilities Maintenance Director. It was observed that in the OR Puxis corridor there were two high pressure oxygen tanks (E-Tanks) that were not properly secured to prevent them from falling and damaging the cylinders.

This tag not met as observed by this surveyor and the Facilities Maintenance Director.
It was observed that in the corridor outside the Anesthesia Office the Med Gas system emergency shutoff for that area was not properly marked indicating what area the shutoffs cover.

It was also observed that the med gas shut off for the Emergency Room is located in a lockable space. It was stated during survey that the space is never locked but the possibility remains that the space can be locked and the key to the space could not be found at time of survey.

It was also observed that the med gas shut off located outside room 209 was not properly marked.

This tag not met as observed by this surveyor and the Facilities Maintenance Director. It was observed that in the electrical room located in the OR corridor the three electrical panels were blocked by storage and equipment making the panels inaccessible.

It was also observed that the electrical power strip being used on a med cart in the OR 2 was not a unit designed for use in patient care areas. (Master Electrician power strip ME901111)

It was observed that the facility is hanging non rated Isolation boxes on patient room doors. The boxes do not meet flame spread requirements. The boxes are made of ABS plastic and do not have a flame spread rating.

This tag not met as observed by this surveyor and the Facilities Maintenance Director. It was observed that the fire doors located near Med Surge and the main entrance lobby had several openings above the doors that were not properly sealed.

It was also observed that the fire door locate near Med Surge did not close and latch properly.

It was also observed that patient room doors #202, 203 & 205 did not close and or latch properly as required to maintain a smoke tight seal.

This tag not met as observed by this surveyor and the Facilities Maintenance Director. It was observed that above the fire doors located outside of X-ray and the doors leading into the patient rooms area have penetrations that are required to be sealed.

This tag not met as observed by this surveyor and the Facilities Maintenance Director. It was observed that the Soiled Utility room located outside of the ER Department does not have the required closure device as required.

This tag not met as observed by this surveyor and the Facilities Maintenance Director. It was observed that in the Emergency Department corridor there were 2 computers on wheels that were being stored in the corridor with chairs in front of them and they were reducing the corridor width.

This tag not met as observed by this surveyor and the Facilities Maintenance Director. It was observed that the PA On Call room on the first floor did not have the required smoke detection. The detector can be a local alarm only detector.

This tag not met as observed by this surveyor and the Facilities Maintenance Director. It was observed that in the OR Clean Utility room, storage was to close to the sprinkler head.

It was also observed that in the Medical Records room a sprinkler head located in the ceiling was missing an escutcheon ring.

This tag not met as observed by this surveyor and the Facilities Maintenance Director. It was observed that in the OR Puxis corridor there were two high pressure oxygen tanks (E-Tanks) that were not properly secured to prevent them from falling and damaging the cylinders.

This tag not met as observed by this surveyor and the Facilities Maintenance Director.
It was observed that in the corridor outside the Anesthesia Office the Med Gas system emergency shutoff for that area was not properly marked indicating what area the shutoffs cover.

It was also observed that the med gas shut off for the Emergency Room is located in a lockable space. It was stated during survey that the space is never locked but the possibility remains that the space can be locked and the key to the space could not be found at time of survey.

It was also observed that the med gas shut off located outside room 209 was not properly marked.

This tag not met as observed by this surveyor and the Facilities Maintenance Director. It was observed that in the electrical room located in the OR corridor the three electrical panels were blocked by storage and equipment making the panels inaccessible.

It was also observed that the electrical power strip being used on a med cart in the OR 2 was not a unit designed for use in patient care areas. (Master Electrician power strip ME901111)