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Based on observation of surveyor 16732 and 34673 on August 27th 2014 the following doors open to patient room corridors to not close properly with evidence as follows:

1) Patient room door 204 does not latch

2) Kitchen door in OB wing has door wedge holding door open

3) Kitchen door in ASU wing has door stop attached to door holding door open

4) Clean linen utility closed in Emergency Room has door wedge holding door open


The safety officer and administrative maintenance/support assistant were present during this observation.

Based on observation of surveyor 16732 and 34673 on August 27, 2014

Two stair enclosures on 3rd floor (two separate wings) have fire rated doors that have 3 holes in top of doors where a magnetic locking device was removed leaving the door compromised.


The safety officer and administrative maintenance/support assistant were present during this observation.

Based on observation of surveyor 16732 and 34673 on August 27, 2014 the following hazardous areas are not properly fire rated protected or non resistant with to the passage of smoke evidence as follows:


1) Pump Room has penetrations in ceiling, phone cords thru wall and plumbing piping .

2) Boiler room number two has ceiling penetrations and cracked sheet rock in ceiling that is falling down.

3) The mechanical room off of the loading dock has penetrations in walls.

4) The storage room next to the oxygen storage room has pipe penetration.

5) Mechanical room 3rd floor has penetrations in wall and floor. A cementitious composite was used around piping for firestopping and the product is not listed for that use.

6) Air handler room 3rd floor has penetrations in ceiling and floor making the area non smoke resistant. A cementitious composite was used around piping for firestopping and the product is not listed for that use.

7) Both concourse observation areas in main hospital corridor are open to corridor with combustible storage and no walls/doors to make the area smoke resistant.

8) Garage ceiling has penetrations.

9) Second floor mechanical room has penetrations. A cementitious composite was used around piping for firestopping and the product is not listed for that use.

10) Open ceiling in lab supply room.



The safety officer and administrative maintenance/support assistant were present during this observation.

Based on observation of surveyor 16732 and 34673 on August 27, 2014 following exit access was not readily accessible with evidence as follows:

1) Laundry cart stored in exit access leading to rear exit door of laundry room.

2) Patient care corridors have computer on wheels and two medication carts on wheel stored and plugged in charging in corridor




The safety officer and administrative maintenance/support assistant were present during this observation.

Based on observation of surveyor 16732 and 34673 on August 27th 2014

1) Respiratory therapy treatment room has lock on door that patient cannot open without special knowledge.



The safety officer and administrative maintenance/support assistant were present during this observation.

Based on observation of surveyor 16732 and 34673 on August 27th 2014 following areas missing exit signs with evidence as follows:

1) In front of doors leading to sleep study area

2) Nursing education (old ICU area) that is being used for patient/family consultation area.


The safety officer and administrative maintenance/support assistant were present during this observation.

Based on record review of surveyor 16732 and 34673 on August 27, 2014

There is a fire drill missing in the last quarter of the year for 2013.



The facility manager and safety officer were present during this record review.

Based on observation of surveyor 16732 and 34673 on August 27th, 2014 an area does not have smoke detector with evidence as follows:

The physicians sleeping room has no smoke detector/horn strobe.

The safety officer and administrative maintenance/support assistant were present during this observation.

Based on observation of surveyor 16732 and 34673 on August 27, 2014 following sprinkler deficiencies were found with evidence as follows:

1) Phone/data cable attached to sprinkler piping in loading dock area.

2) There is no spare head for the type being used in the hall way going into laundry

3) Sprinkler head obstructed by exit sign upon entrance into the ASU unit.

4) Escutcheon plate missing from sprinkler head in x-ray room 3.







The safety officer and administrative maintenance/support assistant were present during this observation.

Based on observation of surveyor 16732 and 34673 on August 27th 2014 the oxygen storage room is not properly rated with evidence as follows:

Oxygen storage/manifold room has open area in rear that is not 1 hour fire rated. There was a window taken out and the construction of the wall was not finished.




The safety officer and administrative maintenance/support assistant were present during this observation.

Based on record review of surveyor 16732 on August 27th, 2014:

1) The nitrous oxide manifold room has an electrical outlet that less than 5 feet above the floor (4-3.1.1.2)

2) The zone valve box located across from the nurses station controlling the flow of medical gases to 322, 324-336, 338 and family room needs to have the family room added to the label. (4-3.1.2.3)

3) The zone valve box located across from the nurses station controlling the flow of medical gases to 301, 303, 305-316, 319, family room need to be labeled appropriately with the rooms it controls (4-3.1.2.3)

4) Room 301- 2nd vacuum inlet leaks (4-3.3.2.5)

5) Room 340 - vacuum inlet leaks (4-3.3.2.5)

6)The nitrous oxide high alarm does not sound when tested (4-3.1.2.2)

7) When the nitrous oxide secondary in use alarm is sounded the nitrous oxide high pressure alarm lights up on the panels (4-3.1.2.2)

8) The oxygen high pressure alarm sounded at 68 psig and needs to be adjusted to sound at 60 psig (4-3.1.2.2)

9) The area alarm panel located at the nurses station of surgical services is not operational (4-3.1.2.2)

10) The area alarm panel located at the nurses station in LDRP does not have a constant pressure display for each medical gas (4-3.1.2.3)

11) The zone valve box located in the DRIP waiting room has no pressure indicators (4-3.1.2.3)

12) The alarm panel located right of exam room in emergency department does not have a constant pressure display for each medical gas (4-3.1.2.3)

13) The zone valves controlling the flow of gases to the operating rooms have not pressure indicators on the patient side of he valves (4-3.1.2.3)

14) The zone valve box located behind the doors leading to the surgical services has no pressure indicators located on the patient side of the valves. (4-3.1.2.3)

15) The zone valve boxes located the acute care have no pressure indicators on the patient side of the valves. (4-3.1.2.3)

16) The zone valve box located behind the doors leading to surgical services has no area alarm monitoring the medical gases (4-3.1.2.2)

17) The zone valve box left of the CT room controls the flow of medical gases to another zone valve (4-3.1.2.2)

18) The oxygen valve located across from nurses station controlling rooms 301, 303,305-316, 319 and family room leaks at the stem in the off position (4-3.1.2.3)

19) The medical air zone valve located behind the door leading into surgical services leaks when in the on position (4-3.1.2.3)

20) The medical air zone valve located across from the nurses station leaks at the stem (4-3.1.2.3)

21) Nursery - 1st medical air outlet leaks with the adapter attached (4-3.4.1.1)

22) Operating room 4 - 1st medical air outlet on the ceiling leaks (4-3.4.1.1)

23) Room 206 oxygen outlet leaks (4-5.4.1.3)

Based on observation of surveyor 16732 and 34673 on August 27th 2014:

1) Nursery has a power relocation tap with a piece of medical equipment plugged in. The power relocation tap is not listed to be used with medical equipment.

2) Insect bug trap light at end of hallway in ASU plugged in with extension cord.

3) Two electrical junction boxes in patient area of Emergency Room were missing covers.


The safety officer, facility manager and administrative maintenance/support assistant were present during this observation.