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Based on observations during the survey walk of the Building 1 facility on the afternoon of 11/05/12, while being accompanied by the Director of Plant Operations and Director of Quality Specialist, the facility failed to maintain the egress corridor. The egress corridor contained medical gas outlets at emergency ' s triage alcove, which opens into the emergency department's lobby and its exit egress pathway. Patient care can not occur in an egress corridor.
Corridors shall be separated from all other areas by partitions complying with 18.3.6.2. through 18.3.6.5 unless otherwise permitted by the following: (1) Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (1) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.

Based on observations during the survey walk of the Building 2 facility on the morning of 11/06/12, while being accompanied by the Director of Plant Operations and Director of Quality Specialist and Director of Safety, the facility failed to assure the protection of a hazardous room. A self-closing or automatic-closing device was non-operational at the equipment storage, near the rehab gym.

Based on observations during the survey walk of the facility on the afternoon of 11/05/12, while being accompanied by the Director of Plant Operations and Director of Quality Specialist, the facility failed to provide a safe egress route. The mechanical room had several appropriate egress exits marked. However, one exit sign led into a hazardous room.

Based on observations during the survey walk of the facility on the afternoon of 11/05/12, while being accompanied by the Director of Plant Operations and Director of Quality Specialist, the facility failed to provide the direction of the egress path. No exit sign existed inside the preteam administration suite.

Based on observations during the survey walk of the Building 2 facility on the morning of 11/06/12, while being accompanied by the Director of Plant Operations and Director of Quality Specialist and Director of Safety, the facility failed to maintain the smoke detector. The smoke detector was covered in dust particles in the attic ' s mechanical room.

Based on observations during the survey walk of the Building 2 facility on the morning of 11/06/12, while being accompanied by the Director of Plant Operations and Director of Quality Specialist and Director of Safety, the facility failed to provide an acceptable means to protect the means of egress. Beds impeded into the exit egress pathway, near the pool room.

Based on observations during the survey walk of the facility on the afternoon of 11/05/12, while being accompanied by the Director of Plant Operations and Director of Quality Specialist, the facility failed to assure that the essential electrical system was in full compliance. A delayed egress door was supplied with power from the critical branch of the essential electrical system (1CCLB). This electrical room was near the imaging department. This egress door should be powered by the life safety branch panel board. The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.

Based on observations during the survey walk of the Building 2 facility on the morning of 11/06/12, while being accompanied by the Director of Plant Operations and Director of Quality Specialist and Director of Safety, the facility failed to assure that the essential electrical system was in full compliance. Time clock was supplied with power from the life safety branch of the essential electrical system. The facility stated that no time clock existing. Verify that the time cock does not exist and update directory. If the time clock is powered by the life safety branch, move this to another panel board that is not the life safety panel board.

Based on observations during the survey walk of the Building 1 facility on the afternoon of 11/05/12, while being accompanied by the Director of Plant Operations and Director of Quality Specialist, the facility failed to maintain the egress corridor. The egress corridor contained medical gas outlets at emergency ' s triage alcove, which opens into the emergency department's lobby and its exit egress pathway. Patient care can not occur in an egress corridor.
Corridors shall be separated from all other areas by partitions complying with 18.3.6.2. through 18.3.6.5 unless otherwise permitted by the following: (1) Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (1) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.

Based on observations during the survey walk of the Building 2 facility on the morning of 11/06/12, while being accompanied by the Director of Plant Operations and Director of Quality Specialist and Director of Safety, the facility failed to assure the protection of a hazardous room. A self-closing or automatic-closing device was non-operational at the equipment storage, near the rehab gym.

Based on observations during the survey walk of the facility on the afternoon of 11/05/12, while being accompanied by the Director of Plant Operations and Director of Quality Specialist, the facility failed to provide a safe egress route. The mechanical room had several appropriate egress exits marked. However, one exit sign led into a hazardous room.

Based on observations during the survey walk of the facility on the afternoon of 11/05/12, while being accompanied by the Director of Plant Operations and Director of Quality Specialist, the facility failed to provide the direction of the egress path. No exit sign existed inside the preteam administration suite.

Based on observations during the survey walk of the Building 2 facility on the morning of 11/06/12, while being accompanied by the Director of Plant Operations and Director of Quality Specialist and Director of Safety, the facility failed to maintain the smoke detector. The smoke detector was covered in dust particles in the attic ' s mechanical room.

Based on observations during the survey walk of the Building 2 facility on the morning of 11/06/12, while being accompanied by the Director of Plant Operations and Director of Quality Specialist and Director of Safety, the facility failed to provide an acceptable means to protect the means of egress. Beds impeded into the exit egress pathway, near the pool room.

Based on observations during the survey walk of the facility on the afternoon of 11/05/12, while being accompanied by the Director of Plant Operations and Director of Quality Specialist, the facility failed to assure that the essential electrical system was in full compliance. A delayed egress door was supplied with power from the critical branch of the essential electrical system (1CCLB). This electrical room was near the imaging department. This egress door should be powered by the life safety branch panel board. The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.

Based on observations during the survey walk of the Building 2 facility on the morning of 11/06/12, while being accompanied by the Director of Plant Operations and Director of Quality Specialist and Director of Safety, the facility failed to assure that the essential electrical system was in full compliance. Time clock was supplied with power from the life safety branch of the essential electrical system. The facility stated that no time clock existing. Verify that the time cock does not exist and update directory. If the time clock is powered by the life safety branch, move this to another panel board that is not the life safety panel board.