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Administrator and Director of Maintenance, the facility failed to maintain corridors. Alcoves were open to egress corridor with unattended coffee pots. No smoke detection was observed to be present. This occurred at L&D and emergency department's egress corridors

Based on observations during the tour of the facility on the afternoon of 2/05/2015, with the Administrator and Director of Maintenance, the facility failed to provide an exit sign marking the exit path. This occurred in the egress corridor, near old surgery department and the material management department. There was one exit sign in the corridor but two ways to egress are required upon entering the egress corridor. If one exit is becomes blocked, the other exit is marked and accessible.

Based on observations during the tour of the facility on the afternoon of 2/05/2015, with the Administrator and Director of Maintenance, the facility failed to maintain a rated barrier. Door did not latch at the door frame when the door was in a closed position at both cath lab's clean supply and VFD control room.





Based on observations during the tour of the facility on the afternoon of 2/05/2015, with the Administrator and Director of Maintenance, the facility failed to assure the doors in egress corridors had the required smoke control amenities. Cath Lab recovery room ' s double doors had a gap between the door ' s meeting edges. This could allow smoke from the environmental care room to enter the egress corridor. A smoke tight seal at the meeting edges of the doors when closed should be provided.

Based on observations during the tour of the facility on the afternoon of 2/05/2015, with the Administrator and Director of Maintenance, the facility failed to provide a sprinklered smoke compartment. The entire smoke compartment was sprinklered except for the home health care room ' s closet

Based on observations during the tour of the facility on the afternoon of 2/05/2015, with the Administrator and Director of Maintenance, the facility failed to maintain the fire alarm system. Escutcheon plates used with a recessed or flush-type sprinkler head were not part of a listed assembly at several locations throughout the facility.

Based on observations during the tour of the facility on the morning of 2/05/2015, with the Administrator and Director of Maintenance, the facility did not have a reliable fire extinguisher. Pressure gauge reading or indicator was not in operable range or position at ICU corridor.

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Based on observations during the tour of the facility on the afternoon of 2/05/2015, with the Administrator and Director of Maintenance, the facility failed to provide acceptable exiting out the designated exit door. The door required two operations to open in an emergency and was located at old surgery department. Only one operation is allowed to open an exit door per NFPA 101, 2003: 7.2.1.5.9.2 ..... The releasing mechanism shall open the door with not more than one releasing operation


Based on review of records during the survey of facility on the afternoon of 2/05/2015, attended by the Administrator and Risk Management, the facility failed to provide documentation that the grounding system at inpatient care areas is being tested. The electrical grounding of duplex outlets in general patient care areas shall be tested annually and critical care areas tested semi-annually. This includes lineisolation monitors (if applicable).The facility must initiate a file to retain these records.
Receptacle testing in patient care areas shall be tested as follows:
Physical integrity of each receptacle. (Visual)
Continuity of the grounding of each receptacle. (Test)
Correct polarity of hot and neutral connections in each receptacle. (Test)
The retention force of the grounding blade shall be not less than 4 oz. (test)

Based on observations during the tour of the facility on the morning of 2/05/2015, with the Administrator and Director of Maintenance, the facility failed to ensure that the Type I essential electrical service (EES) is in accordance with NFPA 99. Ensure all panel boards powered by generator are permanently labeled "LIFE SAFETY", "CRITICAL" or "EQUIPMENT", as applicable to identify which branch they serve.




Based on observations during the tour of the facility on the afternoon of 2/05/2015, with the Administrator and Director of Maintenance, the facility failed to maintain the type I EES system. Electrical panel boards were unlocked at public corridor, near ICU.

Based on observations during the tour of the facility on the afternoon of 2/05/2015, with the Administrator and Director of Maintenance, the facility failed to provide acceptable location for alcohol based hand rub dispensers. Dispenser were installed over an ignition source (electrical outlets) near operating room 2.