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During the Recertification survey, based on observations and staff interviews, the facility failed to ensure that the interior finish for rooms and spaces not used for corridors or exitways was maintained in accordance with NFPA 101, 19.3.3.1, 19.3.3.2

Findings include:

Observation on 04-24-13 to 04-26-13 revealed that:

1. In the Cancer Center the equipment storage room across from room 2003 had water damage to a ceiling tile.
2. In the Main building there was damage to the drywall above the slop sink located across from the 5th floor west nurses station.
3. In the Tower the janitors closet across from room 818 had damage to ceramic tiles and the drywall corner.

The above items were verified by the Operations Manager at the time of discovery. He had the above items corrected by the end of the survey.

During the Recertification survey, based on observations and staff interviews, the facility failed to ensure that the vertical openings were maintained in accordance with NFPA 101,8.2.5.6 and 19.3.1.1.

Findings include:

Observation on 04-25-13 revealed that the fire rated doors for the elevator F lobby in labor and delivery would not latch when tested. The Operations Manager had the latch repaired while we finished survey labor and delivery.

During the Recertification survey, based on observations and staff interviews, the facility failed to ensure that the smoke barriers were maintained in accordance with NFPA 101, 19.3.7.3 and 19.3.7.5.

Findings include:

Observation on 04-25-13 revealed that smoke barrier wall outside the pharmacy had an open unprotected penetration above the ceiling. The Operations Manager had the penetration sealed with in an hour.

During the Recertification survey, based on observations and staff interviews, the facility failed to ensure that the one hour fire rated construction for hazardous areas was maintained in accordance with NFPA 101 8.4.1 and 19.3.5.4.

Findings include:

Observation on 04-24-13 to 04-26-13 revealed that:

1. In the Main Building the 4th floor storage room across from elevator D had combustible storage and the door was not self closing when tested.
2. In the Main Building the storage room door across from room 561 had a gap along the latch edge which prevented the room from being smoke tight.
The above items were verified by the Operation Manager at the time of discovery. He had both items corrected by the end of the survey.

During the Recertification survey, based on observations and staff interviews, the facility failed to ensure that the electrical wiring and equipment was maintained in accordance with NAPA 70.

Findings include:

Observation on 04-24-13 to 04-26-13 revealed that:

1. In the Cancer Center the coffee machine with a permanent water supply was not plugged into a GFCI outlet.
2. In the Heart Center the staff area next to room 8526 had a electrical cord running through the door way and plugged into an outlet outside the office.
3. In the Main Building the coffee machine with a permanent water supply in the ICU was not plugged into a GFCI outlet.
4. In the Main Building the communication room across from room 569 had a powerstrip plugged into a powerstrip.

The above items were verified by the Operation Manager at the time of discovery. He had the above items corrected by the end of the survey.

During the Recertification survey, based on observations and staff interviews, the facility failed to ensure that the interior finish for rooms and spaces not used for corridors or exitways was maintained in accordance with NFPA 101, 19.3.3.1, 19.3.3.2

Findings include:

Observation on 04-24-13 to 04-26-13 revealed that:

1. In the Cancer Center the equipment storage room across from room 2003 had water damage to a ceiling tile.
2. In the Main building there was damage to the drywall above the slop sink located across from the 5th floor west nurses station.
3. In the Tower the janitors closet across from room 818 had damage to ceramic tiles and the drywall corner.

The above items were verified by the Operations Manager at the time of discovery. He had the above items corrected by the end of the survey.

During the Recertification survey, based on observations and staff interviews, the facility failed to ensure that the vertical openings were maintained in accordance with NFPA 101,8.2.5.6 and 19.3.1.1.

Findings include:

Observation on 04-25-13 revealed that the fire rated doors for the elevator F lobby in labor and delivery would not latch when tested. The Operations Manager had the latch repaired while we finished survey labor and delivery.

During the Recertification survey, based on observations and staff interviews, the facility failed to ensure that the smoke barriers were maintained in accordance with NFPA 101, 19.3.7.3 and 19.3.7.5.

Findings include:

Observation on 04-25-13 revealed that smoke barrier wall outside the pharmacy had an open unprotected penetration above the ceiling. The Operations Manager had the penetration sealed with in an hour.

During the Recertification survey, based on observations and staff interviews, the facility failed to ensure that the one hour fire rated construction for hazardous areas was maintained in accordance with NFPA 101 8.4.1 and 19.3.5.4.

Findings include:

Observation on 04-24-13 to 04-26-13 revealed that:

1. In the Main Building the 4th floor storage room across from elevator D had combustible storage and the door was not self closing when tested.
2. In the Main Building the storage room door across from room 561 had a gap along the latch edge which prevented the room from being smoke tight.
The above items were verified by the Operation Manager at the time of discovery. He had both items corrected by the end of the survey.

During the Recertification survey, based on observations and staff interviews, the facility failed to ensure that the electrical wiring and equipment was maintained in accordance with NAPA 70.

Findings include:

Observation on 04-24-13 to 04-26-13 revealed that:

1. In the Cancer Center the coffee machine with a permanent water supply was not plugged into a GFCI outlet.
2. In the Heart Center the staff area next to room 8526 had a electrical cord running through the door way and plugged into an outlet outside the office.
3. In the Main Building the coffee machine with a permanent water supply in the ICU was not plugged into a GFCI outlet.
4. In the Main Building the communication room across from room 569 had a powerstrip plugged into a powerstrip.

The above items were verified by the Operation Manager at the time of discovery. He had the above items corrected by the end of the survey.