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Based on observation during tour and staff verification it was determined this facility failed to ensure the door openings in the one hour fire rated barrier serving also as a smoke barrier had at least a 60 minute fire protection rating. This had the potential to affect all those utilizing this area of the facility. The patient census was 148 at the beginning of the survey.

Findings include:

Facility tour took place on 03/20/12 to 03/21/12 with staff members F, G and H. During tour of the second floor north wing at the double doors near the medical surgical unit, observation was made of a gap greater than one eighth inch between the door leafs when in the closed position.

This observation was verified by all staff members present during the tour on 03/21/12. This deficiency was corrected by the facility during the survey process. The facility placed an astragal along the edge of the door in order to eliminate the gap between the door leafs.

Based on observation during tour and staff verification it was determined this facility failed to ensure the door openings in the two hour fire rated barrier serving also as a smoke barrier and a separation between occupancies, had at least a 120 minute fire protection rating. This had the potential to affect all those utilizing this area of the facility. The patient census was 148 at the beginning of the survey.

Findings include:

Facility tour took place on 03/20/12 and 03/21/12 with staff members F, G and H. During tour of the outer north corridor of the emergency department and at the double doors separating the emergency department from the business occupancy, observation was made of a gap greater than one eighth inch between the door leafs when in the closed position. A strong draft of air was also noted to be coming from this gap.

This observation was verified by all staff members present during the tour on 03/21/12. This deficiency was corrected by the facility staff during the survey process. The facility placed an astragal along the edge of the door in order to eliminate the gab between the door leafs.

Based on observation during tour and staff verification it was determined this facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition specifically pertaining to dust and debris on the sprinkler pendant and location of a sprinkler pendant near devices that may inhibit the spray pattern upon activation of the sprinkler system. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 148.

Findings include:

Facility tour took place on 03/20/12 through 03/21/12 with staff members F, G and H. Observation was made of sprinkler pendants coated with dust and debris and/or located near devices which may inhibit the spray pattern upon activation of the sprinkler system in the following locations:

Sixth floor:
*Within the mechanical room observation was made of an electrical conduit mounted against the sprinkler pendant.

Fourth floor:
*In the corridor at the west side of the north elevators observation was made of three dirty sprinkler heads.
*Within the manager's room just north of the two hour fire rated construction, observation was made of two dirty sprinkler heads.
*Within room numbers 408, 410 and 414 observation was made of dirty sprinkler heads.

Third floor:
*Within room 311 observation was made of one dirty sprinkler head.
*Within the corridor just north of respiratory services, observation was made of two dirty sprinkler heads
*Within the lab area observation was made of dirty sprinkler heads.
*Within the coronary care unit observation was made of dirty sprinkler heads.
*Within room numbers 382, 384 and 393 observation was made of dirty sprinkler heads.
*Within the respiratory services area observation was made of dirty sprinkler heads.

Second floor:
*Dirty sprinkler heads observed in the north conference staff room.
*Within room numbers 290 and 297, observation was made of dirty sprinkler heads.
*Within the clean utility room and female locker room observation was mode of dirty sprinkler heads.
*Dirty sprinkler head observed near the elevators by the OB unit.

First floor:
*Within the dressing room of the diagnostic radiology department dirty sprinkler heads were observed.
*Within the outpatient surgery near the nurses station observation was made of dirty sprinkler heads.
*Dirty sprinkler heads observed in the dish room.
*Within classroom A observation was made of a dirty sprinkler head.
*In the front entrance lobby area multiple sprinkler heads observed to have dust and debris.
*Within the registration area observation was made of dirty sprinkler heads.
*Within the endoscopy area at the nurse's station observation was made of dirty sprinkler heads.
*Within the director of patient access room a dirty sprinkler head was observed.
*Within the outpatient lab near the restroom a dirty sprinkler head was observed.
*Within the critical decision unit's soiled utility room observation was made of a dirty sprinkler head.
*Within the discharge bay room observation was made of a dirty sprinkler head.

The above findings were verified by all staff present during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the medical gas storage area was protected in accordance with the National Fire Protection Association 101 in regards to location of electrical devices. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 148.

Findings include:

Facility tour took place on 03/20/12 and 03/21/12 with staff members F and G. Observation was made within the medical gas storage room of a light switch and thermostat control device mounted at 48 inches above the cement floor. There were several H tanks of oxygen secured within this room at the time of this observation. All staff present verified this finding on 03/21/12. This deficiency was corrected by the facility during the survey process. The facility relocated the light switch and thermostat control device to a location that was greater than five feet above the floor.

Based on observation and staff interview and verification it was determined this facility failed to ensure the means of egress emergency battery operated lights were tested according to the National Fire Protection Association 101, Chapter 7.8. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 38.

Findings include:

Facility tour took place on 03/21/12 with staff members F, G and H. During tour observation was made of several battery operated egress lights. This surveyor requested documentation in order to verify the monthly 30 second and annual 90 minute testing of these devices. The facility manager stated to staff G and this surveyor, they do not have any documentation to verify the testing of the battery operated egress lights.

Based on observation during tour and staff verification it was determined this facility failed to ensure the vertical openings were protected with at least a one half hour fire protection. This had the potential to affect all those utilizing this facility. The patient census within the Women's Imaging on the day of the survey was 27.

Findings include:

Facility tour took place on 03/21/12 with staff members F, G and H. During tour of the exit egress which directed occupants through the vertical opening and out the exit discharge, observation was made of the exit discharge door which failed to positive latch shut. The door latching mechanism was later discovered by staff F and G to have been manipulated to prevent it from positive latching. The facility disengaged the mechanism that was preventing the door from closing with positive latching thus correcting this deficiency on 03/22/12 prior to exit.

Based on observation during tour and staff verification it was determined this facility failed to ensure the door openings in the one hour fire rated barrier serving also as a smoke barrier had at least a 60 minute fire protection rating. This had the potential to affect all those utilizing this area of the facility. The patient census was 148 at the beginning of the survey.

Findings include:

Facility tour took place on 03/20/12 to 03/21/12 with staff members F, G and H. During tour of the second floor north wing at the double doors near the medical surgical unit, observation was made of a gap greater than one eighth inch between the door leafs when in the closed position.

This observation was verified by all staff members present during the tour on 03/21/12. This deficiency was corrected by the facility during the survey process. The facility placed an astragal along the edge of the door in order to eliminate the gap between the door leafs.

Based on observation during tour and staff verification it was determined this facility failed to ensure the door openings in the two hour fire rated barrier serving also as a smoke barrier and a separation between occupancies, had at least a 120 minute fire protection rating. This had the potential to affect all those utilizing this area of the facility. The patient census was 148 at the beginning of the survey.

Findings include:

Facility tour took place on 03/20/12 and 03/21/12 with staff members F, G and H. During tour of the outer north corridor of the emergency department and at the double doors separating the emergency department from the business occupancy, observation was made of a gap greater than one eighth inch between the door leafs when in the closed position. A strong draft of air was also noted to be coming from this gap.

This observation was verified by all staff members present during the tour on 03/21/12. This deficiency was corrected by the facility staff during the survey process. The facility placed an astragal along the edge of the door in order to eliminate the gab between the door leafs.

Based on observation during tour and staff verification it was determined this facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition specifically pertaining to dust and debris on the sprinkler pendant and location of a sprinkler pendant near devices that may inhibit the spray pattern upon activation of the sprinkler system. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 148.

Findings include:

Facility tour took place on 03/20/12 through 03/21/12 with staff members F, G and H. Observation was made of sprinkler pendants coated with dust and debris and/or located near devices which may inhibit the spray pattern upon activation of the sprinkler system in the following locations:

Sixth floor:
*Within the mechanical room observation was made of an electrical conduit mounted against the sprinkler pendant.

Fourth floor:
*In the corridor at the west side of the north elevators observation was made of three dirty sprinkler heads.
*Within the manager's room just north of the two hour fire rated construction, observation was made of two dirty sprinkler heads.
*Within room numbers 408, 410 and 414 observation was made of dirty sprinkler heads.

Third floor:
*Within room 311 observation was made of one dirty sprinkler head.
*Within the corridor just north of respiratory services, observation was made of two dirty sprinkler heads
*Within the lab area observation was made of dirty sprinkler heads.
*Within the coronary care unit observation was made of dirty sprinkler heads.
*Within room numbers 382, 384 and 393 observation was made of dirty sprinkler heads.
*Within the respiratory services area observation was made of dirty sprinkler heads.

Second floor:
*Dirty sprinkler heads observed in the north conference staff room.
*Within room numbers 290 and 297, observation was made of dirty sprinkler heads.
*Within the clean utility room and female locker room observation was mode of dirty sprinkler heads.
*Dirty sprinkler head observed near the elevators by the OB unit.

First floor:
*Within the dressing room of the diagnostic radiology department dirty sprinkler heads were observed.
*Within the outpatient surgery near the nurses station observation was made of dirty sprinkler heads.
*Dirty sprinkler heads observed in the dish room.
*Within classroom A observation was made of a dirty sprinkler head.
*In the front entrance lobby area multiple sprinkler heads observed to have dust and debris.
*Within the registration area observation was made of dirty sprinkler heads.
*Within the endoscopy area at the nurse's station observation was made of dirty sprinkler heads.
*Within the director of patient access room a dirty sprinkler head was observed.
*Within the outpatient lab near the restroom a dirty sprinkler head was observed.
*Within the critical decision unit's soiled utility room observation was made of a dirty sprinkler head.
*Within the discharge bay room observation was made of a dirty sprinkler head.

The above findings were verified by all staff present during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the medical gas storage area was protected in accordance with the National Fire Protection Association 101 in regards to location of electrical devices. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 148.

Findings include:

Facility tour took place on 03/20/12 and 03/21/12 with staff members F and G. Observation was made within the medical gas storage room of a light switch and thermostat control device mounted at 48 inches above the cement floor. There were several H tanks of oxygen secured within this room at the time of this observation. All staff present verified this finding on 03/21/12. This deficiency was corrected by the facility during the survey process. The facility relocated the light switch and thermostat control device to a location that was greater than five feet above the floor.

Based on observation and staff interview and verification it was determined this facility failed to ensure the means of egress emergency battery operated lights were tested according to the National Fire Protection Association 101, Chapter 7.8. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 38.

Findings include:

Facility tour took place on 03/21/12 with staff members F, G and H. During tour observation was made of several battery operated egress lights. This surveyor requested documentation in order to verify the monthly 30 second and annual 90 minute testing of these devices. The facility manager stated to staff G and this surveyor, they do not have any documentation to verify the testing of the battery operated egress lights.

Based on observation during tour and staff verification it was determined this facility failed to ensure the vertical openings were protected with at least a one half hour fire protection. This had the potential to affect all those utilizing this facility. The patient census within the Women's Imaging on the day of the survey was 27.

Findings include:

Facility tour took place on 03/21/12 with staff members F, G and H. During tour of the exit egress which directed occupants through the vertical opening and out the exit discharge, observation was made of the exit discharge door which failed to positive latch shut. The door latching mechanism was later discovered by staff F and G to have been manipulated to prevent it from positive latching. The facility disengaged the mechanism that was preventing the door from closing with positive latching thus correcting this deficiency on 03/22/12 prior to exit.