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Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in one instance on one of five floors.

Findings include:

Observation on August 28, 2013 revealed the following:

1. At 14:40 p.m., on the fourth floor the door to the Endo Decontamination room lacked a self-closing device.

Interview with Maintenance Director and Assistant Maintenance Director on August 29, 2013, at 14:30 p.m., confirmed the hazardous area door issue.

Based on observation and interview, it was determined the facility failed to maintain a stair tower in one instance in one of five floors.

Findings Include:

Observation on August 28-29, 2013 revealed the following:

1. On August 28, 2013, at 12:16 p.m., there were two penetrations in the south stair tower on the fourth floor.

Interview with Maintenance Director and Assistant Maintenance Director on August 29, 2013, at 14:30 p.m., confirmed the stair tower issue.

Based on observation and interview, it was determined that facility failed to maintain exit signs in one instance on one of five floors.

Observation on August 28-29, 2013 revealed the following:

1. On August 29, 2013, at 9:35 a.m., there was an exit sign in the second floor Cath Lab that was not directing to an emergency exit.

Interview with Maintenance Director and Assistant Maintenance Director on August 29, 2013, at 14:30 p.m., confirmed the emergency exit sign issue.

Based on observation and interview, it was determined the facility failed to maintain the fire alarm system in one instance on one of five floors.

Findings Include:

Observation on August 28-29, 2013 revealed the following:

1. On August 29, 2013, at 14:00 p.m., there were several ceiling tiles missing in the basement level morgue affecting proper operation of smoke detectors in this area.

Interview with Maintenance Director and Assistant Maintenance Director on August 29, 2013, at 14:30 p.m., confirmed the fire alarm issue.

Based upon observation and interview, it was determined the facility failed to maintain HVAC systems and requirements in one instance on one of five floors.

Findings include:

Observation on August 28, 2013 revealed the following:

1. At 14:22 p.m., on the fifth floor in Occupational Therapy the dryer exhaust vent was disconnected from the clothes dryer.

Interview with Maintenance Director and Assistant Maintenance Director on August 29, 2013, at 14:30 p.m., confirmed the dryer vent issue.

Based on observation and interview, it was determined the facility failed to maintain medical gas cylinders in one instance on one of five floors.

Findings Include:

Observation on August 28-29, 2013 revealed the following:

1. On August 28, 2013, at 13:07 p.m., there was a carbon dioxide cylinder that was colored red, and an argon cylinder that was colored green in the main medical gas storage area..

Interview with Maintenance Director and Assistant Maintenance Director on August 29, 2013, at 14:30 p.m., confirmed the medical gas issues.

Based upon observation and interview, it was determined the facility failed to maintain electrical requirements in six instances on three of five floors.

Findings include:

Observation on August 28-29, 2013 revealed the following:

1. On August 28, 2013, at 13:15 p.m., there was an extension cord in use in the third floor dialysis room.
2. On August 28, 2013, at 14:50 p.m., on the fourth floor in the PACU there was medical equipment plugged into a surge protector which was plugged into an extension cord.
3. On August 29, 2013, at 08:45 a.m. in a mechanical room in the Cath Lab area on the 2nd floor there was an extension cord plugged into a surge protector.
4. On August 29, 2013, at 08:55 a.m. in a telephone closet by the Cath Lab area on the 2nd floor there was an extension cord plugged into a surge protector.
5. On August 29, 2013, at 9:20 a.m., there was a refrigerator, microwave, and coffee maker on the 2nd floor nursing office plugged into a surge protector.
6. On August 29, 2013, at 13:00 p.m. in the gift shop area on the first floor there was an extension cord in use.

Interview with Maintenance Director and Assistant Maintenance Director on August 29, 2013, at 14:30 p.m., confirmed the electrical issues.

Based upon observation and interview, it was determined the facility failed to maintain hazardous areas in one instance on one of five floors.

Findings include:

Observation on August 28, 2013 revealed the following:

1. At 14:40 p.m., on the fourth floor the door to the Endo Decontamination room lacked a self-closing device.

Interview with Maintenance Director and Assistant Maintenance Director on August 29, 2013, at 14:30 p.m., confirmed the hazardous area door issue.

Based on observation and interview, it was determined the facility failed to maintain a stair tower in one instance in one of five floors.

Findings Include:

Observation on August 28-29, 2013 revealed the following:

1. On August 28, 2013, at 12:16 p.m., there were two penetrations in the south stair tower on the fourth floor.

Interview with Maintenance Director and Assistant Maintenance Director on August 29, 2013, at 14:30 p.m., confirmed the stair tower issue.

Based on observation and interview, it was determined that facility failed to maintain exit signs in one instance on one of five floors.

Observation on August 28-29, 2013 revealed the following:

1. On August 29, 2013, at 9:35 a.m., there was an exit sign in the second floor Cath Lab that was not directing to an emergency exit.

Interview with Maintenance Director and Assistant Maintenance Director on August 29, 2013, at 14:30 p.m., confirmed the emergency exit sign issue.

Based on observation and interview, it was determined the facility failed to maintain the fire alarm system in one instance on one of five floors.

Findings Include:

Observation on August 28-29, 2013 revealed the following:

1. On August 29, 2013, at 14:00 p.m., there were several ceiling tiles missing in the basement level morgue affecting proper operation of smoke detectors in this area.

Interview with Maintenance Director and Assistant Maintenance Director on August 29, 2013, at 14:30 p.m., confirmed the fire alarm issue.

Based upon observation and interview, it was determined the facility failed to maintain HVAC systems and requirements in one instance on one of five floors.

Findings include:

Observation on August 28, 2013 revealed the following:

1. At 14:22 p.m., on the fifth floor in Occupational Therapy the dryer exhaust vent was disconnected from the clothes dryer.

Interview with Maintenance Director and Assistant Maintenance Director on August 29, 2013, at 14:30 p.m., confirmed the dryer vent issue.

Based on observation and interview, it was determined the facility failed to maintain medical gas cylinders in one instance on one of five floors.

Findings Include:

Observation on August 28-29, 2013 revealed the following:

1. On August 28, 2013, at 13:07 p.m., there was a carbon dioxide cylinder that was colored red, and an argon cylinder that was colored green in the main medical gas storage area..

Interview with Maintenance Director and Assistant Maintenance Director on August 29, 2013, at 14:30 p.m., confirmed the medical gas issues.

Based upon observation and interview, it was determined the facility failed to maintain electrical requirements in six instances on three of five floors.

Findings include:

Observation on August 28-29, 2013 revealed the following:

1. On August 28, 2013, at 13:15 p.m., there was an extension cord in use in the third floor dialysis room.
2. On August 28, 2013, at 14:50 p.m., on the fourth floor in the PACU there was medical equipment plugged into a surge protector which was plugged into an extension cord.
3. On August 29, 2013, at 08:45 a.m. in a mechanical room in the Cath Lab area on the 2nd floor there was an extension cord plugged into a surge protector.
4. On August 29, 2013, at 08:55 a.m. in a telephone closet by the Cath Lab area on the 2nd floor there was an extension cord plugged into a surge protector.
5. On August 29, 2013, at 9:20 a.m., there was a refrigerator, microwave, and coffee maker on the 2nd floor nursing office plugged into a surge protector.
6. On August 29, 2013, at 13:00 p.m. in the gift shop area on the first floor there was an extension cord in use.

Interview with Maintenance Director and Assistant Maintenance Director on August 29, 2013, at 14:30 p.m., confirmed the electrical issues.