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Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance on one of three floors.

Findings Include:

Observation on 6/29/11 at 9:29am revealed the following:

The morgue door in the basement level lacked positive latching hardware.

Interview with the facility representative on 6/29/11 at 12:30pm confirmed the lack of hardware.

Based on observation and interview, it was determined the facility failed to maintain the smoke wall in two instances on one of three floors.

Findings Include:

Observation on 6/29/11 revealed the following:

a) At 10:47am, there was a smoke wall penetration above the ceiling in the first floor chapel.
b) At 11:17am, there was a smoke wall penetration above the ceiling in the first floor doctors' lounge area.

Interview with the facility representative on 6/29/11 at 12:30pm confirmed the smoke wall penetrations.

Based on observation and interview, it was determined the facility failed to maintain hazardous area room requirements in three instances on three of three floors.

Findings Include:

Observation on 6/28/11 and 6/29/11 revealed the following:

a) On 6/28/11 at 11:37am, the biohazard doors on the first and second floors and the storage room near the nurses' station on the first floor lack positive latching hardware.
b) On 6/29/11 at 9:17am, the storage room #2 door was not fully closing and latching.
c) On 6/29/11 at 9:36am, the storage room inside the conference room lacks a fire rated door and automatic door closer.

Interview with the facility representative on 6/29/11 at 12:30pm confirmed the hazardous area door issues.

Based on observation and interview, it was determined the facility failed to maintain smoking regulations in one instance on one of three floors.

Findings Include:

Observation on 6/28/11 at 11:59am revealed the following:

There was evidence of smoking in a non-designated area outside off of the first floor lab area.

Interview with the facility representative on 6/29/11 at 12:30pm confirmed the smoking policy violation.

Based on observation and interview, it was determined the facility failed to maintain clear exit access in one instance on one of three floors.

Findings Include:

Observation on 6/29/11 at 11:00am revealed the following:

There were chairs outside the first floor emergency department that were blocking exit access.

Interview with the facility representative on 6/29/11 at 12:30pm confirmed the presence of the chairs.

Based on observation and interview, it was determined the facility failed to maintain gas cylinder requirements.

Findings Include:

Observation on 6/29/11 at 10:01am revealed the following:

There were nitrogen cylinders in the gas storage room that were painted red instead of the required color black.

Interview with the facility representative on 6/29/11 at 12:30pm confirmed the presence of red nitrogen cylinders.

Based on observation and interview, it was determined the facility failed to maintain electrical requirements in one instance on one of three floors.

Findings Include:

Observation on 6/28/11 at 11:50am revealed the following:

There was a toaster oven and a microwave plugged in with a surge protector in the first floor lab area break room.

Interview with the facility representative on 6/29/11 at 12:30pm confirmed items plugged in with the surge protector.

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance on one of three floors.

Findings Include:

Observation on 6/29/11 at 9:29am revealed the following:

The morgue door in the basement level lacked positive latching hardware.

Interview with the facility representative on 6/29/11 at 12:30pm confirmed the lack of hardware.

Based on observation and interview, it was determined the facility failed to maintain the smoke wall in two instances on one of three floors.

Findings Include:

Observation on 6/29/11 revealed the following:

a) At 10:47am, there was a smoke wall penetration above the ceiling in the first floor chapel.
b) At 11:17am, there was a smoke wall penetration above the ceiling in the first floor doctors' lounge area.

Interview with the facility representative on 6/29/11 at 12:30pm confirmed the smoke wall penetrations.

Based on observation and interview, it was determined the facility failed to maintain hazardous area room requirements in three instances on three of three floors.

Findings Include:

Observation on 6/28/11 and 6/29/11 revealed the following:

a) On 6/28/11 at 11:37am, the biohazard doors on the first and second floors and the storage room near the nurses' station on the first floor lack positive latching hardware.
b) On 6/29/11 at 9:17am, the storage room #2 door was not fully closing and latching.
c) On 6/29/11 at 9:36am, the storage room inside the conference room lacks a fire rated door and automatic door closer.

Interview with the facility representative on 6/29/11 at 12:30pm confirmed the hazardous area door issues.

Based on observation and interview, it was determined the facility failed to maintain smoking regulations in one instance on one of three floors.

Findings Include:

Observation on 6/28/11 at 11:59am revealed the following:

There was evidence of smoking in a non-designated area outside off of the first floor lab area.

Interview with the facility representative on 6/29/11 at 12:30pm confirmed the smoking policy violation.

Based on observation and interview, it was determined the facility failed to maintain clear exit access in one instance on one of three floors.

Findings Include:

Observation on 6/29/11 at 11:00am revealed the following:

There were chairs outside the first floor emergency department that were blocking exit access.

Interview with the facility representative on 6/29/11 at 12:30pm confirmed the presence of the chairs.

Based on observation and interview, it was determined the facility failed to maintain gas cylinder requirements.

Findings Include:

Observation on 6/29/11 at 10:01am revealed the following:

There were nitrogen cylinders in the gas storage room that were painted red instead of the required color black.

Interview with the facility representative on 6/29/11 at 12:30pm confirmed the presence of red nitrogen cylinders.

Based on observation and interview, it was determined the facility failed to maintain electrical requirements in one instance on one of three floors.

Findings Include:

Observation on 6/28/11 at 11:50am revealed the following:

There was a toaster oven and a microwave plugged in with a surge protector in the first floor lab area break room.

Interview with the facility representative on 6/29/11 at 12:30pm confirmed items plugged in with the surge protector.