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Based on observation and interview, the facility failed to assure corridor doors closed to a positive latch. (NFPA 101, 19-3.6.3.) The findings include:Observation and interview with the Maintenance Director, on June 16, 2010 between 10:00 a.m. and 2:00 p.m. confirmed the following corridor doors failed to close to a positive latch; the 1st floor surgery dirty supply door, biohazard storage room door by 210, room next to 305, both basement medical records rooms, and basement housekeeping room doors.

Based on observation and interview, the facility failed to assure corridor fire doors closed to a positive latch.
The findings include:
Observation and interview with the Maintenance Director, on June 16, 2010 between 10:00 a.m. and 2:00 p.m. confirmed corridor fire doors by the outpatient lab, Labor and delivery rooms, by 210, by 325, and basement doors by Volunteer Services office would not close to a positive latch.

Based on observation and interview, the facility failed to assure hazardous area ' s fire rated construction is maintained.
The findings include:
Observation and interview with the Maintenance Director, on June 16, 2010 at 2:00 p.m. confirmed unsealed penetrations in the generator room ceiling above the electrical panels, kitchen ceiling above the steam table, boiler room ceiling and the boiler room far corner (2-hour rating) has no fire caulk. in the large 16-inch by 8-inch opening stuffed with mineral wool only.

Based on observation, the facility failed to ensure smoke detectors were located at least three (3) feet from an air supply.
The findings include:
Observation and interview with the Maintenance Director, on June 16, 2010 at 1:45 p.m., confirmed the corridor smoke detector next to room 305 was located 18-inches from an air diffuser.

Based on observation and record review, the facility failed to assure the sprinkler system was maintained quarterly.
The findings include:
Observation and record review with the Maintenance Director, June 16, 2010 at 1:45 p.m., confirmed there was no quarterly sprinkler system maintenance performed (NFPA 25, Table 9-1)
Based on observation and record review, the facility failed to assure the sprinkler system was not used to support non-system components. (NFPA 13, 9-1.1.7)
The findings include:
Observation and interview with the Maintenance Director,on June 16, 2010 at 1:50 p.m. confirmed blue computer wiring above the lay in ceiling, in the 3rd floor corridor by the biohazard room, was supported by sprinkler piping.

Based on observation and interview, the facility failed to assure stainless steel fire extinguishers complied were hydrostatically tested every five (5) years (NFPA 10-5.2)..
The findings include:
Observation and interview with the Maintenance Director, on June 16, 2010 at 10:05 a.m. confirmed the K-class fire extinguisher located in the kitchen was new in 2004 and had not had the required hydrostatic test.

Based on observation and record review, the facility failed to clean the kitchen hood every six months.
The findings include:
Observation with the Maintenance Director in the kitchen, on June 16, 2010 at 8:25 a.m. revealed damaged hood baffles and visible areas inside the hood above the baffles with an excessive buildup of grease and lint. The kitchen hood was not provided with a sticker indicating the hood had been cleaned or the date last cleaned.

Based on observation and interview, the facility failed to assure commercial cooking equipment was provided with a drip tray and collection container.
The findings include:
Observation and interview with the Maintenance Director in the kitchen, on June 16, 2010 at 8:15 a.m. confirmed the exhaust hood system had a drip tray that was not provided with a grease collection container (NFPA 96, 3-2.6).

Based on record review, the facility failed to assure medical gas systems complied with NFPA 99 and 99C.
The findings include:
Record review with the Maintenance Director, on June 16, 2010 at 8:15 a.m. revealed the medical gas system had an annual evaluation of the piped Oxygen and vacuum systems indicating; surgery recovery area has no zone valve, surgery recovery area has no medical gas alarm panel,. There is no main line alarm in the surgery area, stress room has no zone valve for vacuum, hallway oxygen outlet leaks with adapter inserted, operating room #2 vacuum has reduced flow, C-section room has no zone valve for vacuum, The bulk oxygen equipment pad and vehicle pad are not located 8 foot from the inlet to underground sewer or drainage systems, there is not at least three feet of clearance around all components of the system for operations and maintenance purposes, reserve cylinders are not protected against accumulation of ice and snow or continuous exposure to direct rays of the sun, .there are no visual signs for " reorder liquid " , " changeover to reserve " , and " reserve pressure low. " , The high/low pressure master alarm pressure switch is not connected with a demand check fitting, there is no gage installed next to the high/low line pressure master alarm pressure switch, the source valve is not labeled, the source valve is not a three-piece valve with indicating handle and brazing extensions, the main valve is not labeled, The local audible and visual signal when reserve or lag vacuum pump is in operation is not wired to the master alarm, each vacuum pump does not have a check valve to prevent backflow through off-cycle units, each vacuum pump does not have isolation valves on intake piping, there are not sufficient flexible couplings installed in the piping to and from the vacuum equipment, and there is no line pressure low master alarm vacuum switch.

Based on observation and record review, the facility failed to assure each operating room had its own zone valve box outside each operating room.
The findings include:
Record review with the Maintenance Director, on June 16, 2010 at 8:15 a.m. revealed the medical gas system inspection report indicated both operating rooms had no zone valve box to shut off oxygen in the area. Observation in the surgery suite with the Maintenance Director, on June 16, 2010 at 10:15 a.m. confirmed a single zone valve for both operating rooms was located in the emergency room. This valve also serves the emergency room station outlets.

Based on observation and interview, the facility failed to assure two Medical Master Gas Alarm panels were provided (NFPA 99C).
The findings include:
Record review with the Maintenance Director, on June 16, 2010 at 8:15 a.m. revealed the medical gas system inspection report indicated the facility " has only one Medical Master Gas Alarm panels. Interview with the Maintenance Director, on June 16, 2010 at 8:15 a.m. confirmed this finding.

Based on observation and interview, the facility failed to provide battery-powered emergency lighting in the Emergency Generator and Automatic Transfer switch room (NFPA 110, 5-3.1.) and in two (2) of two (2) operating rooms.

The findings include:

Observation and interview with the Maintenance Director, on June 16, 2010 at 2:40 p.m. confirmed the emergency generator/automatic transfer switch room locations were not provided with battery-powered emergency lighting.

Observation and interview with the Maintenance Director, on June 16, 2010 at 11:40 a.m. confirmed the surgical suite operating rooms #1 and #2 were not provided with battery-powered emergency lighting.

Based on observation and interview, the facility failed to provide a remote annunciator for the Emergency Generator (NFPA 99, 3-4.1.1.15)

The findings include:

Observation and interview with the Maintenance Director, on June 16, 2010 at 2:40 p.m. confirmed no remote annunciator was provided.

Based on observation and interview, the facility failed to assure electrical panels had the required three-feet clear space in front of them (NFPA 70,110-16 (d)).
The findings include:
Observation and interview with the Maintenance Director, on June 16, 2010 at 8:15 a.m. confirmed there were carts in front of the electrical panels in the kitchen dishwasher area and a table in front of the panel by the ice cream freezer.