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Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire-proofing. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect 3 of the 115 staff that were working.

FINDINGS INCLUDE:
On 07/11/2011 at 1:51 pm surveyor #18107 observed in the Mechanical Penthouse smoke compartment on the Penthouse floor in the 4101-Plumbing and Water Tanks Room, that fire-proofing was missing from a structural steel beam. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic), staff H (Dir. Of Diagnostic Services), and staff Q (Bldg. Services Coord.).

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Based on observation and interview, the facility did not provide corridor separation doors with doors with positive-latching hardware, and self-latching inactive doors. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect 75 of the 128 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/12/2011 at 2:31 pm surveyor #18107 observed in the 1SCW smoke compartment on the First floor in the 1121-Dining Room of Food Service Suite, that the corridor door to Dining Room would not positively self-latch when pushed to a closed position. The dining room double doors would not close and the maintenance staff did not know how long this condition existed at the time of findings. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M (Food & Nutritional Srvs.), staff L (Dir. of Food Service ) and staff C (Maintenance Mechanic).

2. On 07/12/2011 at 3:34 pm surveyor #18107 observed in the 2SCE smoke compartment on the Second floor in the OR's #1 thru #10, that the inactive door leaf on pairs of corridor doors would not positively self-latch when pushed to a closed position because they did not have automatic flush bolts. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5, exception 4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic) and staff Q (Bldg. Services Coord.).

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Based on observation and interview, the facility did not enclose hazardous rooms with doors having positive-latching hardware. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect 75 of the 128 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/11/2011 at 10:36 am surveyor #18107 observed in the 2SCW smoke compartment on the Second floor in the 2608-Soiled Utility Room, that the door would not positively self-latch when released because the latch mechanism would not work. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic), staff H (Dir. Of Diagnostic Services), and staff G (Dir. Of Inpat. Services).

2. On 07/12/2011 at 2:33 pm surveyor #18107 observed in the 1SCW smoke compartment on the First floor in the 1122-Dirty Dishes Return Room of Food Service Suite, that the door would not positively self-latch when released because the air pressure from the adjoining dining room prevented the door from closing when the fire shutter to the kitchen is closed. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M (Food & Nutritional Srvs.), staff L (Dir. of Food Service ) and staff C (Maintenance Mechanic).

______________________________________

Based on observation and interview, the facility did not provide egress paths at all times with compliant egress path. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect 20 of the 128 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/12/2011 at 3:37 pm surveyor #18107 observed in the 2SCE smoke compartment on the Second floor in the 2430-Surgical Corridor, that the egress path was not compliant. Two suture carts were parked in the surgical corridor reducing the exit width to less than 8'-0" in clear and unobstructed width. This observed situation was not compliant with NFPA 101 (2000 edition), section 18.2.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic) and staff Q (Bldg. Services Coord.).

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Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings and ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 3 of the 7 smoke compartments and had the potential to affect 78 of the 128 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/11/2011 at 10:45 am surveyor #18107 observed in the 3SCN smoke compartment on the Third floor in the Corridor-3106 between 304 & 305 Inpatient Sleeping Rooms, that the escutcheon ring on the sprinkler was not tight to the ceiling. This gap may reduce the response time of the sprinkler in the space and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic), staff H (Dir. Of Diagnostic Services), and staff E (Inpatient Manager).

2. On 07/11/2011 at 10:55 am surveyor #18107 observed in the 3SCN smoke compartment on the Third floor in the Corridor-3201 between 311 & 312 Inpatient Sleeping Rooms, that the escutcheon ring on the sprinkler was not tight to the ceiling. This gap may reduce the response time of the sprinkler in the space and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic), staff H (Dir. Of Diagnostic Services), and staff E (Inpatient Manager).

3. On 07/11/2011 at 10:56 am surveyor #18107 observed in the 3SCN smoke compartment on the Third floor in the Corridor-3201 between 311 & 312 Inpatient Sleeping Rooms, that the escutcheon ring on the sprinkler was not tight to the ceiling. This gap may reduce the response time of the sprinkler in the space and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic), staff H (Dir. Of Diagnostic Services), and staff E (Inpatient Manager).

4. On 07/11/2011 at 1:21 pm surveyor #18107 observed in the 1SCW smoke compartment on the First floor in the 1521-Information Technical Services Room, that there was one or more unsealed holes near the ceiling. The holes included cable wiring penetrations in the ceiling with a hole around penetrations of at least 1/2 inch each. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic), staff H (Dir. Of Diagnostic Services), and staff Q (Bldg. Services Coord.).

5. On 07/12/2011 at 3:22 pm surveyor #18107 observed in the 2SCE smoke compartment on the Second floor in the Sterilizer Equipment Room, that there was one or more unsealed holes near the ceiling. The holes included three pipes penetrating the ceiling with at least 1/2 inches of opening around each penetration. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic) and staff Q (Bldg. Services Coord.).

6. On 07/12/2011 at 3:31 pm surveyor #18107 observed in the 2SCE smoke compartment on the Second floor in the 2420-Sub-Sterile Room, that there was one or more unsealed holes near the ceiling. The holes included 2 inch opening in ceiling behind the flash sterilizer. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic) and staff Q (Bldg. Services Coord.).

7. On 07/12/2011 at 3:39 pm surveyor #18107 observed in the 2SCE smoke compartment on the Second floor in the 2425-Sub-Sterile Room, that there was one unsealed hole near the ceiling. The hole included one copper pipe penetrating the ceiling with at least 1-1/2 inches of opening around the pipe because the insulation was removed from around the pipe where it previously went through the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic) and staff Q (Bldg. Services Coord.).

______________________________________

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect 20 of the 128 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/12/2011 at 3:26 pm surveyor #18107 observed in the 2SCE smoke compartment on the Second floor in the Operating Room #10, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included medical air pressure identified on the gauges throughout the surgery area at 42 lbs. including at zone shutoff, which is below the threshhold for Medical Air usage within a hospital, per NFPA 99, Table 4-5.1.2.12. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.4 and NFPA 99 (1999 edition), Chapter 4 Standard for Health Care Facilities. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic) and staff Q (Bldg. Services Coord.).

______________________________________

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with compliant electrical panels with complete directories. This deficiency occurred in 3 of the 7 smoke compartments, and had the potential to affect 78 of the 128 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/11/2011 at 1:08 pm surveyor #18107 observed in the 1SCW smoke compartment on the First floor in the 1518-Normal Electrical Room, that the electrical code was not followed. Electrical Rooms are not to be used as storage rooms especially for 3 charcoal grilles and several bags of charcoal that are considered combustible and these spaces are not allowed to have anything in them except items specific to the electrical support and electrical equipment. This observed situation was not compliant with NFPA 70 (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic), staff H (Dir. Of Diagnostic Services), and staff Q (Bldg. Services Coord.).

2. On 07/11/2011 at 1:39 pm surveyor #18107 observed in the 3SCN smoke compartment on the Third floor in the 3243-Electrical Room, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #3HA was incorrectly labeled to the JCI Transformer Switch. The switch was observed in the 'off' position. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic), staff H (Dir. Of Diagnostic Services), and staff Q (Bldg. Services Coord.).

3. On 07/12/2011 at 3:44 pm surveyor #18107 observed in the 2SCE smoke compartment on the Second floor in the 2423-Operating Room #6, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel # Isolation Panel, in OR #6 was not labeled as well as several other Operating Rooms. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic) and staff Q (Bldg. Services Coord.).

______________________________________

Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire-proofing. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect 3 of the 115 staff that were working.

FINDINGS INCLUDE:
On 07/11/2011 at 1:51 pm surveyor #18107 observed in the Mechanical Penthouse smoke compartment on the Penthouse floor in the 4101-Plumbing and Water Tanks Room, that fire-proofing was missing from a structural steel beam. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic), staff H (Dir. Of Diagnostic Services), and staff Q (Bldg. Services Coord.).

______________________________________

Based on observation and interview, the facility did not provide corridor separation doors with doors with positive-latching hardware, and self-latching inactive doors. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect 75 of the 128 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/12/2011 at 2:31 pm surveyor #18107 observed in the 1SCW smoke compartment on the First floor in the 1121-Dining Room of Food Service Suite, that the corridor door to Dining Room would not positively self-latch when pushed to a closed position. The dining room double doors would not close and the maintenance staff did not know how long this condition existed at the time of findings. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M (Food & Nutritional Srvs.), staff L (Dir. of Food Service ) and staff C (Maintenance Mechanic).

2. On 07/12/2011 at 3:34 pm surveyor #18107 observed in the 2SCE smoke compartment on the Second floor in the OR's #1 thru #10, that the inactive door leaf on pairs of corridor doors would not positively self-latch when pushed to a closed position because they did not have automatic flush bolts. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5, exception 4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic) and staff Q (Bldg. Services Coord.).

______________________________________

Based on observation and interview, the facility did not enclose hazardous rooms with doors having positive-latching hardware. This deficiency occurred in 2 of the 7 smoke compartments, and had the potential to affect 75 of the 128 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/11/2011 at 10:36 am surveyor #18107 observed in the 2SCW smoke compartment on the Second floor in the 2608-Soiled Utility Room, that the door would not positively self-latch when released because the latch mechanism would not work. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic), staff H (Dir. Of Diagnostic Services), and staff G (Dir. Of Inpat. Services).

2. On 07/12/2011 at 2:33 pm surveyor #18107 observed in the 1SCW smoke compartment on the First floor in the 1122-Dirty Dishes Return Room of Food Service Suite, that the door would not positively self-latch when released because the air pressure from the adjoining dining room prevented the door from closing when the fire shutter to the kitchen is closed. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M (Food & Nutritional Srvs.), staff L (Dir. of Food Service ) and staff C (Maintenance Mechanic).

______________________________________

Based on observation and interview, the facility did not provide egress paths at all times with compliant egress path. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect 20 of the 128 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/12/2011 at 3:37 pm surveyor #18107 observed in the 2SCE smoke compartment on the Second floor in the 2430-Surgical Corridor, that the egress path was not compliant. Two suture carts were parked in the surgical corridor reducing the exit width to less than 8'-0" in clear and unobstructed width. This observed situation was not compliant with NFPA 101 (2000 edition), section 18.2.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic) and staff Q (Bldg. Services Coord.).

______________________________________

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings and ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 3 of the 7 smoke compartments and had the potential to affect 78 of the 128 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/11/2011 at 10:45 am surveyor #18107 observed in the 3SCN smoke compartment on the Third floor in the Corridor-3106 between 304 & 305 Inpatient Sleeping Rooms, that the escutcheon ring on the sprinkler was not tight to the ceiling. This gap may reduce the response time of the sprinkler in the space and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic), staff H (Dir. Of Diagnostic Services), and staff E (Inpatient Manager).

2. On 07/11/2011 at 10:55 am surveyor #18107 observed in the 3SCN smoke compartment on the Third floor in the Corridor-3201 between 311 & 312 Inpatient Sleeping Rooms, that the escutcheon ring on the sprinkler was not tight to the ceiling. This gap may reduce the response time of the sprinkler in the space and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic), staff H (Dir. Of Diagnostic Services), and staff E (Inpatient Manager).

3. On 07/11/2011 at 10:56 am surveyor #18107 observed in the 3SCN smoke compartment on the Third floor in the Corridor-3201 between 311 & 312 Inpatient Sleeping Rooms, that the escutcheon ring on the sprinkler was not tight to the ceiling. This gap may reduce the response time of the sprinkler in the space and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic), staff H (Dir. Of Diagnostic Services), and staff E (Inpatient Manager).

4. On 07/11/2011 at 1:21 pm surveyor #18107 observed in the 1SCW smoke compartment on the First floor in the 1521-Information Technical Services Room, that there was one or more unsealed holes near the ceiling. The holes included cable wiring penetrations in the ceiling with a hole around penetrations of at least 1/2 inch each. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic), staff H (Dir. Of Diagnostic Services), and staff Q (Bldg. Services Coord.).

5. On 07/12/2011 at 3:22 pm surveyor #18107 observed in the 2SCE smoke compartment on the Second floor in the Sterilizer Equipment Room, that there was one or more unsealed holes near the ceiling. The holes included three pipes penetrating the ceiling with at least 1/2 inches of opening around each penetration. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic) and staff Q (Bldg. Services Coord.).

6. On 07/12/2011 at 3:31 pm surveyor #18107 observed in the 2SCE smoke compartment on the Second floor in the 2420-Sub-Sterile Room, that there was one or more unsealed holes near the ceiling. The holes included 2 inch opening in ceiling behind the flash sterilizer. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic) and staff Q (Bldg. Services Coord.).

7. On 07/12/2011 at 3:39 pm surveyor #18107 observed in the 2SCE smoke compartment on the Second floor in the 2425-Sub-Sterile Room, that there was one unsealed hole near the ceiling. The hole included one copper pipe penetrating the ceiling with at least 1-1/2 inches of opening around the pipe because the insulation was removed from around the pipe where it previously went through the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic) and staff Q (Bldg. Services Coord.).

______________________________________

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping. This deficiency occurred in 1 of the 7 smoke compartments, and had the potential to affect 20 of the 128 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 07/12/2011 at 3:26 pm surveyor #18107 observed in the 2SCE smoke compartment on the Second floor in the Operating Room #10, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included medical air pressure identified on the gauges throughout the surgery area at 42 lbs. including at zone shutoff, which is below the threshhold for Medical Air usage within a hospital, per NFPA 99, Table 4-5.1.2.12. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.4 and NFPA 99 (1999 edition), Chapter 4 Standard for Health Care Facilities. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic) and staff Q (Bldg. Services Coord.).

______________________________________

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with compliant electrical panels with complete directories. This deficiency occurred in 3 of the 7 smoke compartments, and had the potential to affect 78 of the 128 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/11/2011 at 1:08 pm surveyor #18107 observed in the 1SCW smoke compartment on the First floor in the 1518-Normal Electrical Room, that the electrical code was not followed. Electrical Rooms are not to be used as storage rooms especially for 3 charcoal grilles and several bags of charcoal that are considered combustible and these spaces are not allowed to have anything in them except items specific to the electrical support and electrical equipment. This observed situation was not compliant with NFPA 70 (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic), staff H (Dir. Of Diagnostic Services), and staff Q (Bldg. Services Coord.).

2. On 07/11/2011 at 1:39 pm surveyor #18107 observed in the 3SCN smoke compartment on the Third floor in the 3243-Electrical Room, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #3HA was incorrectly labeled to the JCI Transformer Switch. The switch was observed in the 'off' position. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic), staff H (Dir. Of Diagnostic Services), and staff Q (Bldg. Services Coord.).

3. On 07/12/2011 at 3:44 pm surveyor #18107 observed in the 2SCE smoke compartment on the Second floor in the 2423-Operating Room #6, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel # Isolation Panel, in OR #6 was not labeled as well as several other Operating Rooms. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff B (Facilities Director), staff C (Maintenance Mechanic) and staff Q (Bldg. Services Coord.).

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