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Based on observations during the survey of the facility, on the afternoon of 01/06/2015, the required control valve signs identifying the portion of the building served were not observed. (NFPA 13 (2002 ed.), §6.7.4 - Identification of Valves. 6.7.4.1 - All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. 6.7.4.2 - The identification sign shall be secured with corrosion-resistant wire, chain, or other aproved means. 6.7.4.3 - The control valve sign shall identify the portion of the building served.)

Emergency system electrical receptacles in Critical Care Areas must be identified and indicate the electrical panelboard and circuit number supplying them in accordance with NFPA 70 National Electrical Code. 9.6.1.4

This STANDARD is not being met as evidenced by:
Based on observations during the survey of the facility, on the afternoon of 01/06/2015 and the morning of 01/07/2015, the required identification of emergency system electrical receptacles in Critical Care Areas were not observed at: (1) The Pre-Operation Area of the Surgical Suite; (2) In the Central Observation Unit on the 2nd Floor; (3) In the Cardiac Services Unit; (4) At the 10th Floor of the South Tower; (5) At the 4th Floor of the Heart Center; and, (6) At the West Tower 4th Floor Patient Care Areas. (NFPA 72 (2001), 517.19(A) - Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them.)


Doors required by the authority having jurisdiction to be kept closed are required to be kept closed, either by self-closing or automatic means. 19.3.6.3.5

This STANDARD is not being met as evidenced by:
Based on observations during the survey of the facility, on the morning of 01/07/2015, the door to the anteroom of the West Tower 4th Floor patient isolation room was not observed to be equipped with a door closer, such that the door stayed fixed in an open position. (NFPA 101 (2003), 19.3.6.3.5 - Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction.)

Based on observations during the survey of the facility, on the afternoon of 01/06/2015, the required control valve signs identifying the portion of the building served were not observed. (NFPA 13 (2002 ed.), §6.7.4 - Identification of Valves. 6.7.4.1 - All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. 6.7.4.2 - The identification sign shall be secured with corrosion-resistant wire, chain, or other aproved means. 6.7.4.3 - The control valve sign shall identify the portion of the building served.)

Emergency system electrical receptacles in Critical Care Areas must be identified and indicate the electrical panelboard and circuit number supplying them in accordance with NFPA 70 National Electrical Code. 9.6.1.4

This STANDARD is not being met as evidenced by:
Based on observations during the survey of the facility, on the afternoon of 01/06/2015 and the morning of 01/07/2015, the required identification of emergency system electrical receptacles in Critical Care Areas were not observed at: (1) The Pre-Operation Area of the Surgical Suite; (2) In the Central Observation Unit on the 2nd Floor; (3) In the Cardiac Services Unit; (4) At the 10th Floor of the South Tower; (5) At the 4th Floor of the Heart Center; and, (6) At the West Tower 4th Floor Patient Care Areas. (NFPA 72 (2001), 517.19(A) - Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them.)


Doors required by the authority having jurisdiction to be kept closed are required to be kept closed, either by self-closing or automatic means. 19.3.6.3.5

This STANDARD is not being met as evidenced by:
Based on observations during the survey of the facility, on the morning of 01/07/2015, the door to the anteroom of the West Tower 4th Floor patient isolation room was not observed to be equipped with a door closer, such that the door stayed fixed in an open position. (NFPA 101 (2003), 19.3.6.3.5 - Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction.)