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Based on a review of the records on the morning of 1/13/10, with the director of maintenance, the facility failed to provide documentation of flame spread characteristics for the cubicle curtains. The facility must initiate a file to retain these records.

Based on observations during the tour of the facility on the morning of 1/13/10, with the director of maintenance, the facility failed to provide an acceptable means to protect the corridor. The Corridor door into the Outpatient ' s Soiled Utility room did not latch when closed by its automatic closer.

Based on observations during the tour of the facility on the morning of 1/13/10, with the director of maintenance, the facility failed to assure an acceptable enclosure of hazardous areas. The central sterile vestibule had been converted to a storage room for combustible materials (i.e. cardboard boxes and linens). Both doors did not have closures and the walls of this room did not go up to the deck and were not 1-hour rated. Ensure that either the room is converted back to a central sterile vestibule or that this room has a 1-hour fire rated enclosure (1-hour fire rated walls with 3/4-hour fire rated door assemblies with a closure on the door).

Based on observations during the tour of the facility on the morning of 1/13/10, with the director of maintenance, the facility failed to provide an acceptable clear means of egress to the exterior door. A copy machine was located in the exit corridor in the radiology suite. This machine must be relocated out of the exit corridor.

Based on observations during the tour of the facility on the morning of 1/13/10, with the director of maintenance, the facility failed to keep storage of materials the correct distance below the sprinkler heads in the Radiology medical records room. Paper was stored above the 18 inch plane that starts from the bottom of the sprinkler head and goes downward. Items may not be stored above this plane because this can interfere with the sprinkler coverage.

Based on observations during the tour of the facility on the morning of 1/13/10, with the director of maintenance, the facility failed to assure that the essential electrical system was in full compliance. Nurse call was supplied with power from the life safety branch of the essential electrical system at panel ELS2, located near the ICU suite. Nurse call shall be supplied with power from the critical branch of the essential electrical system.

Based on observations during the tour of the facility on the morning of 1/13/10, with the director of maintenance, the facility had flex conduit installed in panelboard ELS2, an emergency-powered panelboard. This situation must be mitigated. The wiring of the emergency system shall mechanically protected by raceways.

Based on a review of the records on the morning of 1/13/10, with the director of maintenance, the facility failed to provide documentation of flame spread characteristics for the cubicle curtains. The facility must initiate a file to retain these records.

Based on observations during the tour of the facility on the morning of 1/13/10, with the director of maintenance, the facility failed to provide an acceptable means to protect the corridor. The Corridor door into the Outpatient ' s Soiled Utility room did not latch when closed by its automatic closer.

Based on observations during the tour of the facility on the morning of 1/13/10, with the director of maintenance, the facility failed to assure an acceptable enclosure of hazardous areas. The central sterile vestibule had been converted to a storage room for combustible materials (i.e. cardboard boxes and linens). Both doors did not have closures and the walls of this room did not go up to the deck and were not 1-hour rated. Ensure that either the room is converted back to a central sterile vestibule or that this room has a 1-hour fire rated enclosure (1-hour fire rated walls with 3/4-hour fire rated door assemblies with a closure on the door).

Based on observations during the tour of the facility on the morning of 1/13/10, with the director of maintenance, the facility failed to provide an acceptable clear means of egress to the exterior door. A copy machine was located in the exit corridor in the radiology suite. This machine must be relocated out of the exit corridor.

Based on observations during the tour of the facility on the morning of 1/13/10, with the director of maintenance, the facility failed to keep storage of materials the correct distance below the sprinkler heads in the Radiology medical records room. Paper was stored above the 18 inch plane that starts from the bottom of the sprinkler head and goes downward. Items may not be stored above this plane because this can interfere with the sprinkler coverage.

Based on observations during the tour of the facility on the morning of 1/13/10, with the director of maintenance, the facility failed to assure that the essential electrical system was in full compliance. Nurse call was supplied with power from the life safety branch of the essential electrical system at panel ELS2, located near the ICU suite. Nurse call shall be supplied with power from the critical branch of the essential electrical system.

Based on observations during the tour of the facility on the morning of 1/13/10, with the director of maintenance, the facility had flex conduit installed in panelboard ELS2, an emergency-powered panelboard. This situation must be mitigated. The wiring of the emergency system shall mechanically protected by raceways.