HospitalInspections.org

This tag not met as observed by this surveyor and the facility maintenance director. It was observed the facility old elevator shaft is now being used for an equipment room and storage area on different levels. This area is required to be sprinkler protected on each level to protect the area in the event of a fire.

This tag not met as observed by this surveyor and the facility maintenance director. It was observed that the facility sprinkler records identified that on the 9 January, 2013 inspection/testing of the facility dry system the system did not pass the internal inspection and a flushing of the system is required. As of the date of the survey no action has been to correct this deficiency.

This tag not met as observed by the facility maintenance director and this surveyor. It was observed that more than 300 cubic ft of oxygen was being stored in the smoke compartment of the 3rd floor. Storage consisted of 3 "E" tanks (72 cubic ft) and one green container that contains 275 cubic ft of oxygen.

The following additional deficiencies were observed: 1) Two fire doors did not close and latch properly (the door outside med surge near room 62 and one of the fire doors in the supply area), 2) The main elevator room requires a smoke detector and heat detector to be installed. The smoke detector is to be tied to the elevator recall system. 3) The blue board insullation located in the Enviromental storage room is required to be covered by a 15 minute thermal barrier.