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Based upon observations, facility failed to ensure that two of the storage rooms in the basement were in accordance with the 2000 edition of the Life Safety Code, NFPA 101(National Fire Protection Association), Findings included:

Surveyor observed between 3:30-4:30pm on 6/22/10 that Engineering storage and Dietary storage rooms did not have self-closing devices on corridor doors. This is not in accordance with NFPA 101, 200): 19.3.2.1.

Based upon observations, facility failed to ensure that exit access from two areas was in accordance with NFPA 101, 2000. Findings included:

Surveyor observed between 9:30 and 10:30 am on 6/23/10 that double doors from surgery to PACU and elevator lobby and one exit door from the Labortory had dead bolt locks therby requiring two actions to release the doors. This is not in accordance with NFPA 101, 2000: 7.2.1.5.4. Doors shall be operable with not more than one releasing operation.

Based upon observations, facility failed to ensure that fire alarm circuits for main fire alarm control panel were in accordance with NFPA 72, National Fire Alarm Code. Findings included:

Surveyor observed between 9:30 and 10:30 am on 6/23/10 that fire alarm circuit in panel board closet outside main public elevators on first level was not idenitified in accordance with NFPA 72. Fire alarm system control panels shall be permanently labeled to identify the panel and circuit breakers that supply power to them - NFPA 72, 1996: 1-5.2.8.2. Also, the circuit breaker at the electrical panel board shall be identified with a red marking and identified as "FIRE ALARM CIRCUIT CONTROL".

Based upon observations, facility failed to ensure that sprinkler systems were in accordance with NFPA 13, Standard for Fire Sprinklers. Findings included:

Surveyor observed between 9:30 and 10:30 am on 6/23/10 that one of two flush sprinkler heads in the Pharmacy IV prepartion room was missing an escutcheon plate. This is not in accordance with NFPA 13, 1996: 2-2.5.2. Escutcheon plates used with recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Based upon observations, the facility failed to ensure electrical system is maintained in accordance with NFPA 99, Health Care Facilities and NFPA 70, National Electrical Code. Findings included:

1. Surveyor observed between 9:30 and 10:30 am on 6/23/10, that Essential Electrical Panelboards in Surgery Mechanical Room were not properly identified in. accordance to the requirements of NFPA 70, 1996: 110-22, 700-9(a) and NEC, 1996: 110-22 and 700-9(a). The panels for the essential electrical distribution from the alternate power source need to be clearly labeled to indicate the branches that these panels serve. These branch panels labels are required to read; "LIFE SAFETY", "CRITICAL" and "EQUIPMENT". In all electric panel boxes, the circuit directories need to be labeled in accordance to which circuit breakers serve what electrical devices by room name and room number or any equipment with proper name as required by NFPA 70, 1999: 384-13 and NEC, 1999: 384-13.

2. Surveyor observed between 9:30 and 10:30 am on 6/23/10 that records of biomedical equipment did not contain records of maintenance and tesing of electrical system in accordance with NFPA 99, 1999: 3-3.4.2.3 (a)2. Additional testing shall be performed at intervals defined by documentd performance data and 3-3.3.3 Receptacle Testing in Patient Care Areas
(a) The phyiscal integrity of each receptacle shall be confirmed by visual inspection.
(b)The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention forc of the grounding blade of each receptacle shall be not less that 4 oz.

Based upon observations, facility failed to ensure that two of the storage rooms in the basement were in accordance with the 2000 edition of the Life Safety Code, NFPA 101(National Fire Protection Association), Findings included:

Surveyor observed between 3:30-4:30pm on 6/22/10 that Engineering storage and Dietary storage rooms did not have self-closing devices on corridor doors. This is not in accordance with NFPA 101, 200): 19.3.2.1.

Based upon observations, facility failed to ensure that exit access from two areas was in accordance with NFPA 101, 2000. Findings included:

Surveyor observed between 9:30 and 10:30 am on 6/23/10 that double doors from surgery to PACU and elevator lobby and one exit door from the Labortory had dead bolt locks therby requiring two actions to release the doors. This is not in accordance with NFPA 101, 2000: 7.2.1.5.4. Doors shall be operable with not more than one releasing operation.

Based upon observations, facility failed to ensure that fire alarm circuits for main fire alarm control panel were in accordance with NFPA 72, National Fire Alarm Code. Findings included:

Surveyor observed between 9:30 and 10:30 am on 6/23/10 that fire alarm circuit in panel board closet outside main public elevators on first level was not idenitified in accordance with NFPA 72. Fire alarm system control panels shall be permanently labeled to identify the panel and circuit breakers that supply power to them - NFPA 72, 1996: 1-5.2.8.2. Also, the circuit breaker at the electrical panel board shall be identified with a red marking and identified as "FIRE ALARM CIRCUIT CONTROL".

Based upon observations, facility failed to ensure that sprinkler systems were in accordance with NFPA 13, Standard for Fire Sprinklers. Findings included:

Surveyor observed between 9:30 and 10:30 am on 6/23/10 that one of two flush sprinkler heads in the Pharmacy IV prepartion room was missing an escutcheon plate. This is not in accordance with NFPA 13, 1996: 2-2.5.2. Escutcheon plates used with recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Based upon observations, the facility failed to ensure electrical system is maintained in accordance with NFPA 99, Health Care Facilities and NFPA 70, National Electrical Code. Findings included:

1. Surveyor observed between 9:30 and 10:30 am on 6/23/10, that Essential Electrical Panelboards in Surgery Mechanical Room were not properly identified in. accordance to the requirements of NFPA 70, 1996: 110-22, 700-9(a) and NEC, 1996: 110-22 and 700-9(a). The panels for the essential electrical distribution from the alternate power source need to be clearly labeled to indicate the branches that these panels serve. These branch panels labels are required to read; "LIFE SAFETY", "CRITICAL" and "EQUIPMENT". In all electric panel boxes, the circuit directories need to be labeled in accordance to which circuit breakers serve what electrical devices by room name and room number or any equipment with proper name as required by NFPA 70, 1999: 384-13 and NEC, 1999: 384-13.

2. Surveyor observed between 9:30 and 10:30 am on 6/23/10 that records of biomedical equipment did not contain records of maintenance and tesing of electrical system in accordance with NFPA 99, 1999: 3-3.4.2.3 (a)2. Additional testing shall be performed at intervals defined by documentd performance data and 3-3.3.3 Receptacle Testing in Patient Care Areas
(a) The phyiscal integrity of each receptacle shall be confirmed by visual inspection.
(b)The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention forc of the grounding blade of each receptacle shall be not less that 4 oz.