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A) The initial information provided for the building indicates that it is non-combustible construction. Based on random observation with the Operations Manager present the surveyor observed that the Boiler Room has an extension with a plywood roof. This material as sheathing does not comply with the non-combustibility requirements of NFPA 220. The surveyor that this boiler room extends under the portion of the Hospital that supports health care floors. The provider's Life Safety Plans do not identify a two hour fire barrier wall between this portion of the boiler room with wood construction and the portion of the boiler room that support health care above.

A) Based on random observation with the Operations Manager present the surveyor observed that the 3rd Floor Nurse's Station in the North Wing is vacant and does not comply with the exceptions under 19.3.6.1.

Findings include:

The vacant Nurse's Station lacks smoke detection in accordance with 19.3.6.1. This condition could delay detection of a fire that could compromise the exit access corridor.

A) Based on random observation with the Operations Manager present the surveyor observed that require some corridor doors do not have functioning positive latching hardware in accordance with 19.3.6.3.
Findings include:

1) 5th Floor Surgical Unit - The corridor wall (west wall) of the Pre-op and Post-op spaces have a pair of doors each with automatic opening/auto hold-open hardware that is not disengaged so that the doors can latch, when the fire alarm is activated.

Failure to close and latch doors in a fire will allow fire and smoke to spread.

A) Based on direct observation on December 11, 2012, with the Hospital Operation Manager and the Executive VP of Quality, also observing and based upon a review of the Construction Documents for the building dated January 2009, the surveyor finds that the Main Lobby of this facility has a three story open stair that connects to the Lower Level, 1st and 2nd Floors. This stair is open to most of the spaces on the 1st and 2nd Floor and it is open to all 1st and 2nd Floor exit access corridors. The stair is shown on drawings with a one hour separation at the Lower Level. This three story open space does not comply with Section 8.2.5 and more specifically it does not comply with with 8.2.5.5, 8.2.5.6, 8.2.5.7 or 8.2.5.8.

Findings include:

1) The stair is open to the 1st Floor, the large lobby space and waiting areas of the 1st Floor and all of the exit access corridors of the 1st Floor which includes at least two means of egress for the 1st Floor PT/OT space.

2) The stair is open to most spaces on the 2nd Floor including all of the exit access corridors. Exit paths to other enclosed exit stairs must travel through spaces exposed to the open stair.

3) No atrium smoke control system was found

4) Although the Lower Level is identified on plans with a one hour fire barrier separation the fire barrier is incomplete and not installed in accordance with 8.2.5 (fire barriers for vertical openings):

a) Multiple duct penetrations through the one hour barrier (from three sides) lack fire dampers in accordance with NFPA 101 and NFPA 90A and/or lack combination fire/smoke dampers in accordance with ICC Codes.

b) The door to the Teledata Room is a 3/4 hour fire door instead of a one hour B Label door minimum.

c) Two ducts penetrate the stair enclosure wall without fire dampers (see "a" above) and multiple penetrations are not sealed for one hour construction.

d) Two ducts penetrations from Medical Records lack fire dampers (see "a" above).

e) The south wall of the open stair is not constructed as a one hour barrier above the ceiling. There are unsealed penetrations and the wall terminates at an unprotected steel beam (a continuous one hour fire barrier is not provided. Also, one duct penetration lacks a fire damper.

f) See also K021

5) Even with 4 "a" through "f" corrected the open stair will still not comply with 8.2.5.
Failure to install and maintain vertical opening protection will allow fire to spread throughout multiple floors and multiple spaces in a fire emergency.

A) Based on random observation and review of Life Safety Plans the surveyor finds that vertical openings are not installed and maintained in accordance with 19.3.1.1 of NFPA 101.

One finding was observed with the Operation manager present:

2nd Floor (surveyor did not record which wing this was in): there is a storage room behind a stair. This storage room has a pipe chase that penetrates at least the floor above if not more. A fire rated enclosure was not found in accordance with 8.2.5 (NFPA 101) and fire dampers were not found in accordance with NFPA 90A:

1) This chase is not identified as a fire rated enclosure of the Life Safety Plans.

2) The door to the room is fire rated but is not self closing.

3) Two duct penetrations were observed; only one had a fire damper.

4) Access to the shaft at the 3rd Floor was not available.

5) The room is used for storage that is not separated from the shaft.

Failure to maintain vertical opening protection will allow fire to spread from floor to floor in a fire emergency.

A) Based on random observation with the Operations Manager present the surveyor observed that require fire doors or smoke doors are held open by means that do not comply with 7.2.1.8.2.

Findings include:

1) 5th Floor Surgical Unit - Operating Room # 5 has been converted to a storage room and is therefor a hazardous area. The door to this room has a self closing device that includes a hold open function that does not automatically close the door from activation of the fire alarm system and sprinkler system in accordance with 7.2.1.8.

2) 1 South Waiting Room (1101). The door to this space is part of a designated smoke barrier. The door has a self closing device that includes a hold open function that does not automatically close the door from activation of the fire alarm system and sprinkler system in accordance with 7.2.1.8.

Failure to maintain fire separation at doors could allow fire and smoke to spread in a fire emergency.

A) The surveyor finds that a 1 hour, B Label door to the Lower Level open elevator lobby is a fire door in a three story open space. This door has a magnetic hold open device but lacks smoke detection on both sides of the door in accordance with 7.2.1.8 . The provider is not able to identify whether the two smoke detectors in the Lower Level Elevator Lobby will close the fire door upon activation.
Failure to close fire doors automatically in a fire emergency will allow smoke to spread to multiple floors.

A) Based on random observation the surveyor finds that hazardous areas are not always separated from other areas in accordance with 38.3.2. The Loading Dock is a hazardous area. The pair of doors between the Loading Dock and a corridor lacks self closing hardware on an in-activate leaf (8.4.1.2). Failure to maintain hazardous area separations would allow fire and smoke to spread beyond such areas in a five emergency.

A) Based on random observation with the Operations Manager present the surveyor observed that required enclosure of hazardous areas is not provided and maintained in accordance with 19.3.2.1

Findings include:

1) 5th Floor Surgical Unit - Operating Room # 7 has been converted to a storage room and is therefor a hazardous area.

a) The door to this room lacks positive latching hardware.

b) The door has a self closing device that includes a hold open function that does not automatically close the door from activation of the fire alarm system and sprinkler system in accordance with 7.2.1.8.

2) Basement Level

a) Storage Room 0111 has a door that is not self closing.

b) Bio-Hazard Room 0204 has a pair of fire doors. The inactive leaf has a manual flush bolt instead of positive latching hardware.

A) Based on random observation with the Operations Manager present the surveyor observed that required exit enclosures are not always maintained in accordance with 7.2 of NFPA 101.

Findings include:

1) The 5th Floor fire door to the exit stair from the Male Surgical Staff Break Room was taped so that the latch set would not latch. This had been cited on previous surveys. The provider lacks adequate means to prevent re-occurrence.

Failure to maintain fire rated enclosure of the exit will allow fire and smoke to spread into the exit during a fire emergency.

A) Based on random observation and the lack of documentation the surveyor finds that emergency means of egress lighting is not maintained in accordance with 7.9.3 of NFPA 101. Findings include:

1) The 1st Floor and the entire building has emergency lighting (recess lighting system) with battery back up and emergency lighting with battery back up. The provider has no documentation that demonstrates that these lighting systems are tested monthly and annually in accordance with 7.9.3.
Failure to maintain emergency lighting could result in failure.

A) Based on random observation the surveyor finds that illuminated exit sign are not always provided in accordance with 7.10. Findings include: 1st Floor PT/OT: continuous exit signs are not provided. The space has multiple exit paths. One path through an area that includes a number of offices and a nurse's station lack an illuminated exit sign.
Failure to provide exit signs will delay evacuation in an emergency.

A) The surveyor reviewed and used the Life Safety Plans available on site; however, the surveyor finds that this set of documents fails to clearly identify the location of exit access corridor and suite boundaries in 5 West.

A) Based on random observation and interview with the operations manager, the surveyor finds that the sprinkler system is not installed and maintained in accordance with NFPA 13. Findings include:

1) The Lower Level sprinkler control room has a valve that is identified as a main drain. However it is configured as if it is also an inspector's test valve for the Lower Level. It is not identified as such. The provider is not aware of another inspector's test valve for this level and testing and maintenance records (see K62) fail to identify where the inspector's test valves are located.

2) A sprinkler report dated 5/14/12 indicates that an inspector's test valve is missing for the Penthouse. This report does not indicate that the inspector's test valve must be located in the Penthouse. The provider has not documentation that indicates that this has been corrected.

Failure to install and maintain the sprinkler system could result in poor performance of failure during a fire.

A) Based on random observation with the Operations Manager present the surveyor observed that sprinkler installations are not installed and maintained to comply with NFPA 13 - 1999.

Findings include:

1) Missing ceiling tiles in sprinklered areas compromises sprinkler protection. Locations include:

a) 1st Floor X-ray Reception area and Patient Holding area (Project).

b) A Men's Locker Room (1st Floor or Lower Level).

2) The top of Stair # 3 lacks sprinkler protection.

A) Based on personnel interview, random observation and document review the surveyor finds that the sprinkler system is not tested, serviced and maintained in accordance with NFPA 25:

1) Documentation of quarterly flow testing is incomplete. A quarterly fire alarm report dated October 2012 identifies testing of five or five water flow detection devices. This report lacked specifics. The surveyor was not able to find five water flow detection devices in the building and the Hospital Operations Manager was not able to identify the location of five water flow detection devices. See also K056.

a) A quarterly sprinkler report dated 5/14/12 indicates that some form of flow testing was done; however specific testing with the location of each device and the time from water flow to activation of the fire alarm was not documented.

b) No documentation was available on site that demonstrates flow testing of each flow switch for three of four quarters of 2012 and the last quarter of 2012.

2) No annual documentation of testing, service and maintain was found on site for 2012. The only report available was a report dated 5/14/12 and it was identified as a quarterly report for testing and maintenance.

3) The facility has a dry-pipe sprinkler system at a drive through canopy. The quarterly report dated 5/14/12 references this system but does not clearly indicate that it was tested in accordance with NFPA 12/NFPA 25.

a) The report does not include an annual internal inspection of the dry-pipe valve.

b) An attachment to the report indicates that the required three year full flood test has not been performed.

4) There are two back flow devices in the Lower Level sprinkler control room. The tags on both devices did not specifically indicate that an annual back flow test was conducted in accordance with NFPA 25.

Failure to maintain the sprinkler system could result in failure during a fire emergency.

A) Based on review of documentation for the previous 11 months, the surveyor finds that the sprinkler systems are not tested, serviced and maintained in accordance with NFPA 13 and NFPA 25-1999.

Findings include;

1) Documentation of quarterly testing of sprinkler flow switches is incomplete. The records are incomplete and do not demonstrate quarterly testing of each flow switch. Documentation with the date or testing, the location of each device, and the time from water flow to activation of the fire alarm was not found.

2) The Documentation for annual testing and service of multiple dry pipe sprinkler systems is incomplete. The documentation available on site for each system does not clearly identify an internal inspection of each dry pipe valve and does not identify the date for the three year full flood test that is required.

The above find includes but is not limited to the system that protects the ambulance bay and the MRI system.

Failure to test and maintain the sprinkler system could result in failure during a fire.

A) Based on random observation with the Operations Manager present the surveyor observed portable electrical heaters with ceramic heating elements. The provider lacks documentation that indicates that the heating element does not exceed 212 degrees Farenheit.

Locations include but are not limited to:

1) 1st Floor Administration Area

2) 1st Floor Main Lobby Volunteers Desk

Used of unapproved portable heaters could start a fire.

A) Based on random observation with the Operations Manager present the surveyor observed that emergency generators are not installed and maintained in accordance with NFPA 70, 101 and 110.

Findings include:

1) The generator room is isolated from other parts of the building by fire barriers; however that pair of fire doors to the generator room were propped open and the in-active leaf has manual flush bolts instead of positive latching hardware.

This condition will allow fire to spread from the generator room into the electrical room and allow fire to spread from the electrical room into the generator room.

A) Based on random observation and document review of generator testing for twelve months, with the Operations Manager and the Facilities Manager present, the surveyor observed that documentation for monthly generator testing for two or two emergency generators is not completed in accordance with NFPA 110.

Findings include:

1) The surveyor finds that some of the monthly load test documentation identifies the voltage for all three phases while some of the documentation includes the voltage for only two phases of emergency power.

2) The documentation for monthly load testing does not identify the amperage loads for each of three phases of emergency power.

Incomplete documentation could result in an emergency power failure.

A) Based on random observation with the Operations Manager present the surveyor observed that electrical installations and materials do not comply with NFPA 70 - 1999.

Findings include:

1) The provider has a number of extension cords, including home-made extensions cords that are not U L Listed in permanent use in place of required electrical outlets. Locations include:

a) Switchboard area

b) 1st Floor Kitchen - Multiple extension cords in in the cooking line behind the soda area

c) Throughout the 1st Floor Kitchen

Mis-use of electrical extension cords include use in place of permanent installations could cause an electrical fire.

A) The initial information provided for the building indicates that it is non-combustible construction. Based on random observation with the Operations Manager present the surveyor observed that the Boiler Room has an extension with a plywood roof. This material as sheathing does not comply with the non-combustibility requirements of NFPA 220. The surveyor that this boiler room extends under the portion of the Hospital that supports health care floors. The provider's Life Safety Plans do not identify a two hour fire barrier wall between this portion of the boiler room with wood construction and the portion of the boiler room that support health care above.

A) Based on random observation with the Operations Manager present the surveyor observed that the 3rd Floor Nurse's Station in the North Wing is vacant and does not comply with the exceptions under 19.3.6.1.

Findings include:

The vacant Nurse's Station lacks smoke detection in accordance with 19.3.6.1. This condition could delay detection of a fire that could compromise the exit access corridor.

A) Based on random observation with the Operations Manager present the surveyor observed that require some corridor doors do not have functioning positive latching hardware in accordance with 19.3.6.3.
Findings include:

1) 5th Floor Surgical Unit - The corridor wall (west wall) of the Pre-op and Post-op spaces have a pair of doors each with automatic opening/auto hold-open hardware that is not disengaged so that the doors can latch, when the fire alarm is activated.

Failure to close and latch doors in a fire will allow fire and smoke to spread.

A) Based on direct observation on December 11, 2012, with the Hospital Operation Manager and the Executive VP of Quality, also observing and based upon a review of the Construction Documents for the building dated January 2009, the surveyor finds that the Main Lobby of this facility has a three story open stair that connects to the Lower Level, 1st and 2nd Floors. This stair is open to most of the spaces on the 1st and 2nd Floor and it is open to all 1st and 2nd Floor exit access corridors. The stair is shown on drawings with a one hour separation at the Lower Level. This three story open space does not comply with Section 8.2.5 and more specifically it does not comply with with 8.2.5.5, 8.2.5.6, 8.2.5.7 or 8.2.5.8.

Findings include:

1) The stair is open to the 1st Floor, the large lobby space and waiting areas of the 1st Floor and all of the exit access corridors of the 1st Floor which includes at least two means of egress for the 1st Floor PT/OT space.

2) The stair is open to most spaces on the 2nd Floor including all of the exit access corridors. Exit paths to other enclosed exit stairs must travel through spaces exposed to the open stair.

3) No atrium smoke control system was found

4) Although the Lower Level is identified on plans with a one hour fire barrier separation the fire barrier is incomplete and not installed in accordance with 8.2.5 (fire barriers for vertical openings):

a) Multiple duct penetrations through the one hour barrier (from three sides) lack fire dampers in accordance with NFPA 101 and NFPA 90A and/or lack combination fire/smoke dampers in accordance with ICC Codes.

b) The door to the Teledata Room is a 3/4 hour fire door instead of a one hour B Label door minimum.

c) Two ducts penetrate the stair enclosure wall without fire dampers (see "a" above) and multiple penetrations are not sealed for one hour construction.

d) Two ducts penetrations from Medical Records lack fire dampers (see "a" above).

e) The south wall of the open stair is not constructed as a one hour barrier above the ceiling. There are unsealed penetrations and the wall terminates at an unprotected steel beam (a continuous one hour fire barrier is not provided. Also, one duct penetration lacks a fire damper.

f) See also K021

5) Even with 4 "a" through "f" corrected the open stair will still not comply with 8.2.5.
Failure to install and maintain vertical opening protection will allow fire to spread throughout multiple floors and multiple spaces in a fire emergency.

A) Based on random observation and review of Life Safety Plans the surveyor finds that vertical openings are not installed and maintained in accordance with 19.3.1.1 of NFPA 101.

One finding was observed with the Operation manager present:

2nd Floor (surveyor did not record which wing this was in): there is a storage room behind a stair. This storage room has a pipe chase that penetrates at least the floor above if not more. A fire rated enclosure was not found in accordance with 8.2.5 (NFPA 101) and fire dampers were not found in accordance with NFPA 90A:

1) This chase is not identified as a fire rated enclosure of the Life Safety Plans.

2) The door to the room is fire rated but is not self closing.

3) Two duct penetrations were observed; only one had a fire damper.

4) Access to the shaft at the 3rd Floor was not available.

5) The room is used for storage that is not separated from the shaft.

Failure to maintain vertical opening protection will allow fire to spread from floor to floor in a fire emergency.

A) Based on random observation with the Operations Manager present the surveyor observed that require fire doors or smoke doors are held open by means that do not comply with 7.2.1.8.2.

Findings include:

1) 5th Floor Surgical Unit - Operating Room # 5 has been converted to a storage room and is therefor a hazardous area. The door to this room has a self closing device that includes a hold open function that does not automatically close the door from activation of the fire alarm system and sprinkler system in accordance with 7.2.1.8.

2) 1 South Waiting Room (1101). The door to this space is part of a designated smoke barrier. The door has a self closing device that includes a hold open function that does not automatically close the door from activation of the fire alarm system and sprinkler system in accordance with 7.2.1.8.

Failure to maintain fire separation at doors could allow fire and smoke to spread in a fire emergency.

A) The surveyor finds that a 1 hour, B Label door to the Lower Level open elevator lobby is a fire door in a three story open space. This door has a magnetic hold open device but lacks smoke detection on both sides of the door in accordance with 7.2.1.8 . The provider is not able to identify whether the two smoke detectors in the Lower Level Elevator Lobby will close the fire door upon activation.
Failure to close fire doors automatically in a fire emergency will allow smoke to spread to multiple floors.

A) Based on random observation the surveyor finds that hazardous areas are not always separated from other areas in accordance with 38.3.2. The Loading Dock is a hazardous area. The pair of doors between the Loading Dock and a corridor lacks self closing hardware on an in-activate leaf (8.4.1.2). Failure to maintain hazardous area separations would allow fire and smoke to spread beyond such areas in a five emergency.

A) Based on random observation with the Operations Manager present the surveyor observed that required enclosure of hazardous areas is not provided and maintained in accordance with 19.3.2.1

Findings include:

1) 5th Floor Surgical Unit - Operating Room # 7 has been converted to a storage room and is therefor a hazardous area.

a) The door to this room lacks positive latching hardware.

b) The door has a self closing device that includes a hold open function that does not automatically close the door from activation of the fire alarm system and sprinkler system in accordance with 7.2.1.8.

2) Basement Level

a) Storage Room 0111 has a door that is not self closing.

b) Bio-Hazard Room 0204 has a pair of fire doors. The inactive leaf has a manual flush bolt instead of positive latching hardware.

A) Based on random observation with the Operations Manager present the surveyor observed that required exit enclosures are not always maintained in accordance with 7.2 of NFPA 101.

Findings include:

1) The 5th Floor fire door to the exit stair from the Male Surgical Staff Break Room was taped so that the latch set would not latch. This had been cited on previous surveys. The provider lacks adequate means to prevent re-occurrence.

Failure to maintain fire rated enclosure of the exit will allow fire and smoke to spread into the exit during a fire emergency.

A) Based on random observation and the lack of documentation the surveyor finds that emergency means of egress lighting is not maintained in accordance with 7.9.3 of NFPA 101. Findings include:

1) The 1st Floor and the entire building has emergency lighting (recess lighting system) with battery back up and emergency lighting with battery back up. The provider has no documentation that demonstrates that these lighting systems are tested monthly and annually in accordance with 7.9.3.
Failure to maintain emergency lighting could result in failure.

A) Based on random observation the surveyor finds that illuminated exit sign are not always provided in accordance with 7.10. Findings include: 1st Floor PT/OT: continuous exit signs are not provided. The space has multiple exit paths. One path through an area that includes a number of offices and a nurse's station lack an illuminated exit sign.
Failure to provide exit signs will delay evacuation in an emergency.

A) The surveyor reviewed and used the Life Safety Plans available on site; however, the surveyor finds that this set of documents fails to clearly identify the location of exit access corridor and suite boundaries in 5 West.

A) Based on random observation and interview with the operations manager, the surveyor finds that the sprinkler system is not installed and maintained in accordance with NFPA 13. Findings include:

1) The Lower Level sprinkler control room has a valve that is identified as a main drain. However it is configured as if it is also an inspector's test valve for the Lower Level. It is not identified as such. The provider is not aware of another inspector's test valve for this level and testing and maintenance records (see K62) fail to identify where the inspector's test valves are located.

2) A sprinkler report dated 5/14/12 indicates that an inspector's test valve is missing for the Penthouse. This report does not indicate that the inspector's test valve must be located in the Penthouse. The provider has not documentation that indicates that this has been corrected.

Failure to install and maintain the sprinkler system could result in poor performance of failure during a fire.

A) Based on random observation with the Operations Manager present the surveyor observed that sprinkler installations are not installed and maintained to comply with NFPA 13 - 1999.

Findings include:

1) Missing ceiling tiles in sprinklered areas compromises sprinkler protection. Locations include:

a) 1st Floor X-ray Reception area and Patient Holding area (Project).

b) A Men's Locker Room (1st Floor or Lower Level).

2) The top of Stair # 3 lacks sprinkler protection.

A) Based on personnel interview, random observation and document review the surveyor finds that the sprinkler system is not tested, serviced and maintained in accordance with NFPA 25:

1) Documentation of quarterly flow testing is incomplete. A quarterly fire alarm report dated October 2012 identifies testing of five or five water flow detection devices. This report lacked specifics. The surveyor was not able to find five water flow detection devices in the building and the Hospital Operations Manager was not able to identify the location of five water flow detection devices. See also K056.

a) A quarterly sprinkler report dated 5/14/12 indicates that some form of flow testing was done; however specific testing with the location of each device and the time from water flow to activation of the fire alarm was not documented.

b) No documentation was available on site that demonstrates flow testing of each flow switch for three of four quarters of 2012 and the last quarter of 2012.

2) No annual documentation of testing, service and maintain was found on site for 2012. The only report available was a report dated 5/14/12 and it was identified as a quarterly report for testing and maintenance.

3) The facility has a dry-pipe sprinkler system at a drive through canopy. The quarterly report dated 5/14/12 references this system but does not clearly indicate that it was tested in accordance with NFPA 12/NFPA 25.

a) The report does not include an annual internal inspection of the dry-pipe valve.

b) An attachment to the report indicates that the required three year full flood test has not been performed.

4) There are two back flow devices in the Lower Level sprinkler control room. The tags on both devices did not specifically indicate that an annual back flow test was conducted in accordance with NFPA 25.

Failure to maintain the sprinkler system could result in failure during a fire emergency.

A) Based on review of documentation for the previous 11 months, the surveyor finds that the sprinkler systems are not tested, serviced and maintained in accordance with NFPA 13 and NFPA 25-1999.

Findings include;

1) Documentation of quarterly testing of sprinkler flow switches is incomplete. The records are incomplete and do not demonstrate quarterly testing of each flow switch. Documentation with the date or testing, the location of each device, and the time from water flow to activation of the fire alarm was not found.

2) The Documentation for annual testing and service of multiple dry pipe sprinkler systems is incomplete. The documentation available on site for each system does not clearly identify an internal inspection of each dry pipe valve and does not identify the date for the three year full flood test that is required.

The above find includes but is not limited to the system that protects the ambulance bay and the MRI system.

Failure to test and maintain the sprinkler system could result in failure during a fire.

A) Based on random observation with the Operations Manager present the surveyor observed portable electrical heaters with ceramic heating elements. The provider lacks documentation that indicates that the heating element does not exceed 212 degrees Farenheit.

Locations include but are not limited to:

1) 1st Floor Administration Area

2) 1st Floor Main Lobby Volunteers Desk

Used of unapproved portable heaters could start a fire.

A) Based on random observation with the Operations Manager present the surveyor observed that emergency generators are not installed and maintained in accordance with NFPA 70, 101 and 110.

Findings include:

1) The generator room is isolated from other parts of the building by fire barriers; however that pair of fire doors to the generator room were propped open and the in-active leaf has manual flush bolts instead of positive latching hardware.

This condition will allow fire to spread from the generator room into the electrical room and allow fire to spread from the electrical room into the generator room.

A) Based on random observation and document review of generator testing for twelve months, with the Operations Manager and the Facilities Manager present, the surveyor observed that documentation for monthly generator testing for two or two emergency generators is not completed in accordance with NFPA 110.

Findings include:

1) The surveyor finds that some of the monthly load test documentation identifies the voltage for all three phases while some of the documentation includes the voltage for only two phases of emergency power.

2) The documentation for monthly load testing does not identify the amperage loads for each of three phases of emergency power.

Incomplete documentation could result in an emergency power failure.

A) Based on random observation with the Operations Manager present the surveyor observed that electrical installations and materials do not comply with NFPA 70 - 1999.

Findings include:

1) The provider has a number of extension cords, including home-made extensions cords that are not U L Listed in permanent use in place of required electrical outlets. Locations include:

a) Switchboard area

b) 1st Floor Kitchen - Multiple extension cords in in the cooking line behind the soda area

c) Throughout the 1st Floor Kitchen

Mis-use of electrical extension cords include use in place of permanent installations could cause an electrical fire.