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Based on observations, testing, and staff interviews the facility failed to insure that all corridor walls meet the requirements.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following corridor wall deficiencies were noted:

a. 3rd floor Treatment Room, has a louver in the corridor wall,
b. 3rd floor, this floor is not provided with automatic sprinkler protection and the corridor wall is not properly sealed at the deck above,
c. 1st floor, across from the elevator, has a louver in the corridor wall,

An interview with staff M confirmed the findings.

Based on observations, testing and staff interviews, the facility failed to insure that all doors protecting corridor openings meet the requirements.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m., the following corridor door deficiencies were noted:

a. 6th floor, the corridor door to room #647 does not properly close and latch,
b 5th floor, the corridor doors to rooms #501, 502, 504, 505, 512, and 558 do not properly close and latch and have a gap at the top.

The findings were confirmed by staff interview.

Based on observations, testing, and staff interviews the facility failed to insure that all corridor opening requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010, between the hours of 9:00 a. m. - 4:30 p. m., the following corridor door deficiencies were noted:

a. 4th floor, Sleep Room, has a louver in the corridor door,
b. 3rd floor, Activity Room, corridor door has a second leaf that is not auto latching,
c. 3rd floor, Activity Room, corridor door is not self closing,
d. ground floor, dutch door top leaf is not auto latching.

An interview with staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all vertical openings meet the requirements.

The finding are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. and 4:30 p. m. the following vertical openings deficiencies were noted:

a. 9th floor, South Main stairwell has a steel I-beam penetration of a fire wall that is not properly protected,
b. 7th floor, Elevator #6, a steel I-beam penetration that is not properly protected,
c. 6th floor, Elevator #9, a steel I-beam penetration that is not properly protected,
d. 5th floor, Elevator #9, a steel I-beam penetration that is not properly protected.

The findings were confirmed by staff interview.

Based on observations, testing, and staff interviews the facility failed to insure that al vertical opening requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following vertical opening deficiencies were noted:

a. 4th floor South Stairwell has an unprotected steel I-beam in the wall,
b. 3rd floor Elevator 42 has an unsealed penetration above the ceiling,
c. 1st floor Stair C fire wall is not sealed at the deck above,

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that the stairwells meet all the enclosure requirements.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the 1st floor South Stair has a 12" duct penetration without a damper.

An interview with staff M confirmed the findings.

Based on observations and staff interview, the facility failed to insure that smoke barrier walls meet the requirements.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following smoke barrier deficiencies were noted:

a. the 1st floor shell space has part of the rated wall assembly removed,
b. the 1st floor Breast Center has an unsealed sprinkler pipe penetrating the fire wall,


An interview with staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that the smoke barrier walls provide a one half hour fire resistance rating.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. and 4:30 p. m. the following smoke barrier deficiencies were noted:

a. 9th floor, East Hall , unsealed wiring penetration in the fire wall above the smoke barrier doors,
b. 4th floor, smoke wall not properly sealed above the East and Main corridor doors.

The findings were confirmed by staff interview.

Based on observations, testing, and staff interviews the facility failed to insure that all smoke barrier wall requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following smoke barrier deficiencies were noted:

a. 4th floor smoke barrier has an unsealed penetrations above Fire Door #4007,
b. 3rd floor smoke barrier steel I-beam above Fire Door 3-009 is not properly protected,


An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews the facility failed to insure that all smoke barrier doors meet the requirements.

The finding are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the smoke barrier doors #1010 is not provided with a rabbet, bevel, or astragal and is not smoke tight.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all smoke barrier doors meet the requirements.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following smoke barrier door deficiencies were noted:

a. 7th floor, the smoke barrier doors on the North Hall do not properly close,
b 7th floor, the smoke barrier doors on the South Hall do not properly close,
c. 5th floor, the smoke barrier doors #63 do not properly close,
d. 4th floor, the smoke barrier doors #147 do not properly close,
e. 1st floor, smoke barrier doors #064 , 069, 072, and #73.

An interview with staff S1 confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all hazardous area requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that a 50 gal storage cart was located in the corridor near to door #HT-401.

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hour of 9:00 a. m.- 4:30 p. m. the hazardous chemical storage room is not properly sealed around a steel I-beam.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews the facility failed to insure that all hazardous areas are properly protected.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following hazardous area deficiencies were noted:
a. the kitchen's storage room door is a dutch door and the top leaf is not auto latching.
b. the kitchen's corridor doors are not auto latching.
c. 3rd floor, clean linen storage across from room C-314 has an accordion type door that is not rated. ( this floor is not provided with automatic sprinkler protection)

An interview with staff M confirms the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all hazardous areas were properly protected.

The findings are:

During a tour of the facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following deficiencies were noted:

a. the mechanical rooms on the ground floor have double fire doors and the second leaf is not automatic latching,
b. 1st floor file storage room Fire Door #1363 was blocked in an open position.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all hazardous areas were properly protected.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010, at 9:00 a. m. - 4:30 p. m., the following hazardous area deficiencies were noted:

a. 4th floor, Fire Door #153d does not properly close and latch,
b. 3rd floor, unsealed penetration above Fire Door K-3,
c. 2nd floor, there is a gap between the double doors, Fire Doors #441,
d. 2nd floor, Fire Door #371 does not properly close and latch,
e. 2nd floor, Fire Door #370 , was blocked open,
f. 1st floor, Fire Door #462, does not properly close and latch,
g. Basement, Fire Door #477 is on hold open devices and is not provided with smoke detection within 5 feet,
h. Basement, Fire Door #483A is not self closing.

An interview with staff S1 confirmed the findings.

Based on observations, testing, staff interviews the facility failed to insure that all hazardous area requirements are being met. NFPA 99.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following hazardous area deficiencies were noted:

a. the 2hr fire wall separating the Hyperbaric Treatment Area from the remainder of the building has unsealed wiring penetrations,
b. the 2hr fire wall has a non- rated fire extinguisher cabinet penetrating and is not properly protected,
c. the double fire doors in the 2hr fire wall have a second leaf that is not auto-latching.

An interview with staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all stairway requirements are being met. NFPA 101, 2000 Edition, para. 39.2.2.3.1.

The findings are:

During the tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following stair deficiencies were noted:

a. The guard rails are not at least 42" in height,
b. There are spaces in the guard rails that a 4 inch sphere can pass through.

An interview with staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all exit requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following stairwell guardrails deficiencies were noted:

a. the stairwell guardrails are not at least 42 " in height,
b. the guardrails have spaces that a 4 inch sphere can pass through.

An interview with staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all exits and egress requirements are being met.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. , the following stairwell deficiencies were noted:

a. some of the guardrails are not at least 42 inches in height,
b. the guardrails have spaces that a 4 inch sphere can pass through.

An interview staff S1 confirmed the findings.

Based on observations, testing and staff interviews, the facility failed to insure that all stairway requirements are being met. NFPA 101, 2000 Edition, para. 39.2.2.3.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following stairway deficiencies were noted:

a. the guard rails are not at least 42 inches in height,
b. the guard rails have spaces that a 4 inch sphere can pass through.

An interview with staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all exits were accessible at all times. NFPA 101, 2000 Edition, para. 39.2.7.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the exit ramp at the main entrance was not provided with a handrail on both sides.

An interview with staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all egress requirements are being met. NFPA 101, 2000 Edition, para. 39.2.7.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010, between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the exit ramps are not provided with handrails on both sides.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that the exits were accessible at all times.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the delayed egress mechanism on the 1st floor South Stair exit door did not open after 15 seconds.

An interview with staff M confirmed the findings.

Based on observations, testing and staff interviews, the facility failed to insure that all emergency lighting requirements are met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p.m. revealed that the emergency lighting does not provide illumination on all outside exits.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews the facility failed to insure that all emergency lighting requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that not all exits were provided with emergency lighting.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all emergency lighting requirements are being met. NFPA 101, 2000 Edition, para. 39.2.9.1.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010, between the hours of 9:00 a. m. and 4:30 p. m. it was noted that not all exits were provided with emergency lighting.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all emergency lighting requirements are being met. NFPA 101, 2000 Edition, para. 39.2.9.1.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following emergency lighting deficiencies were noted:

a. the emergency lighting units in the corridors would not work properly,
b. there is no emergency lighting provided for all exits.

An interview with staff M confirmed the requirements.

Based on observations, testing, and staff interviews, the facility failed to insure that all emergency lighting requirements are being met. NFPA 101, 2000 Edition, para. 39.2.9.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010, between the hours of 9:00 a. m. - 4:30 p. m. it was noted that emergency lighting is not provided in all areas.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all emergency lighting requirements are being met. NFPA 101, 2000 Edition, para. 39.2.9.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following emergency lighting deficiencies were noted:

a. no emergency lighting provided in the treatment or exam areas of the building,
c. no emergency lighting provided at all exits.

An interview with staff S1 confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all exits are provided with emergency illumination.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that all exits were not provided with emergency lighting.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all exit and directional sign requirements are being met. NFPA 101, 2000 Edition, para. 39.2.10.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 it was noted that the exit sign located near the Appointment Desk was not illuminated.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all exit and directional sign requirements are being met. NFPA 101, 2000 Edition, para. 39.2.10.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th between the hours of 9:00 a. m. - 4:30 p. m. it was noted that exit signs #331EL03 and 331EL06 were not properly illuminated.

An interview with staff S1 confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all exit and directional signs meet the requirements. NFPA 101, 2000 Edition, 39.2.10.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 it was noted that some of the exit and directional signs were not illuminated at the time of this inspection.

An interview with staff M confirmed the findings.

Based on observations, records review, and staff interviews, the facility failed to insure that all emergency plan and fire drills meet the requirements.

The findings are:

During a tour of this facility with staff S1 and staff M on May 3rd thru May 7th, 2010, between the hours of 9:00 a. m. - 4:30 p. m., it was noted that the fire drills were not being held at unexpected times under varying conditions on all shifts.

An interview with staff S1 and staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all fire alarm requirements are being met. NFPA 101, 2000 Edition, para. 39.3.4.1 and 39.3.4.2.

The findings are:

During a tour of this facility with staff S1 and staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following fire alarm deficiencies were noted:

a. The fire alarm pull station is not located near the main entrance/exit,
b. a smoke detector in the corridor is located too close to an HVAC register,
c. a smoke detector in the clean linen storage room is located too close to an HVAC register.

An interview with staff S1 and staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all fire alarm system requirements are being met. NFPA 101, 2000 Edition, para. 39.3.4.1.


The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010, between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the fire alarm panel is showing a trouble signal.

An interview with staff S1 confirmed the findings.

Based on observations, records review, and staff interviews, that facility failed to insure that all fire alarm system requirements were being met.

The findings are:

During a tour of this facility with staff S1 and staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following fire alarm deficiencies were noted:

a. 7th floor Room M-707, the smoke detector is located too close to an HVAC register,
b. 1st floor, Mechanical room, West Tower Annex, the smoke detectors area located greater than 12" from the ceiling,
c. Basement, Main Mechanical room, the smoke and heat detectors are located greater than 12" from the ceiling,
d. Basement, Main Corridor, the smoke detectors are located greater than 12" from the ceiling,
e. A review of the annual fire alarm system test documents revealed that several smoke detectors failed and no corrective action was noted, (see page 62 of the test documents).
f. A review of the annual fire alarm system test documents revealed that the fire door hold open device testing information was not dated,
g. A review of the annual fire alarm system test documents revealed that the smoke and fire damper testing does not include all equipment.

An interview with staff S1 and staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all smoke detector requirements are being met. NFPA 101. 2000 Edition. para. 39.3.4.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the smoke detector #103 is located too close to an HVAC register.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interview the facility failed to insure that all smoke detectors meet the requirements. NFPA 101, 2000 Edition, para. 39.3.4.1.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following smoke detector deficiencies were noted:

a. 1st floor corridor smoke detector located too close to an HVAC register,
b. the smoke detector near the Appointment Desk is located too close to the HVAC register,

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews the facility failed to insure that all smoke detector requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following smoke detector deficiencies were noted:

a. 4th floor, smoke detector outside of the elevator is located too close to a HVAC register,
b. 3rd floor, smoke detector outside of room #305 is located too close to a HVAC register,
c. The Bridge to the Main Hospital, the 2 hour fire doors are not provided with smoke detectors within 5 feet of the doors,

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all smoke detector requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following smoke detector deficiencies were noted:

a. the smoke detector in the soiled utility room #H-641 is located too close to the HVAC register,
b. the smoke detector in room #H-467 is located too close to the HVAC register,
c. the smoke detector located near the main fire alarm panel in the foyer is located too close to the HVAC register.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all smoke detector requirements are being met. NFPA 101, 2000 Edition, para. 39.3.4.1.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the smoke detector in the corridor is located too close to the HVAC register.

An interview with staff M confirmed the requirements.

Based on observations, testing, and staff interviews, the facility failed to insure that all smoke detectors meet the requirements.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following smoke detector deficiencies were noted:

a. The smoke detector located in the 1st floor Cancer Life Waiting room is located too close to the HVAC register.
b. The smoke detector located in the 2nd floor sterile supply closet is located too close to the HVAC register,
c. 1st floor smoke detector in the corridor outside the file storage room is located too close to the HVAC register.

An interview with staff M confirmed the findings.

Based on observations, records review, and staff interview, the facility failed to insure that all automatic sprinkler system requirements are being met.

The findings are:

During a tour of this facility with staff S1 and staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following sprinkler system deficiencies were noted:

a. 2nd floor, Mechanical room #2, South, the ductwork on HVAC unit #66 is wider than 48" without adequate sprinkler coverage beneath,
b. 1st floor, the Lab, the sprinkler heads are blocked by equipment and cabinets,
c. 1st floor, Blood Storage Cooler is not provided with sprinkler protection,
d. Basement, sprinkler eschutcheon plates missing in Environmental Services,
e. Basement, sprinkler system does not cover the entire Communication Storage room,
f. A review of the sprinkler system's annual test documents revealed that the test does not include the static and residual pressures,
g. Not all sprinkler valves are identified as to the areas covered throughout the building.

An interview with staff S1 and staff M confirmed the findings.

Based on observations, records reviews and staff interviews the facility failed to insure that all sprinkler system requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the pressure gauges on the sprinkler system have not been tested in the past 5 years.

An interview with staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all portable fire extinguisher requirements were being met.

The findings are:

During a tour of this facility on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the type K fire extinguisher was mounted farther than 5 feet from the automatic fire extinguishing system manual pull in the kitchen.

An interview with staff M confirms the findings.

Based on observations, records review, and staff interview, the facility failed to insure that all fire extinguisher requirements are being met.

The findings are:

During a tour of this facility with staff S1 and staff M on May 3rd thru May 7th, 2010 during the hours of 9:00 a. .m. - 4:30 p. m. , the annual service records for the portable fire extinguishers has some units listed that were not found or tested with no explanation.

An interview with staff S1 and staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all heating, ventilation, and air-conditioning requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. and 4:30 p. m. it was noted that the ground floor Patient Access office is not provided with an HVAC return duct system.

An interview with staff M confirms the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all cooking facility requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the kitchen's range hood has combustible ceiling tile adjacent to it.

An interview with staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all laundry chute requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd the May 7th, 2010, between the hours of 9:00 a. m - 4:30 p. m. it was noted that the linen chute's fire damper was blocked by excess linens.

An interview with staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that the medical gas storage areas meet all requirements.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010, between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the full and empty medical gas cylinders were not stored separately in properly identified areas.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all medical gas storage requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following medical gas storage area deficiencies were noted:

a. the storage closet is not provided with a powered vent to the outside,
b. the storage area is not properly marked with non-smoking and no smoking signs.

An interview with staff M confirmed the requirements.

Based on observations and staff interviews, the facility failed to insure that all medical gas system requirements are being met.

The finding are:

During a tour of this facility with staff M on May 3rd thru May 7th between the hour of 9:00 a. m. - 4:30 p. m. the following medical gas system deficiencies were noted:

a. no fire extinguisher provided for the med. gas bulk storage area,
b. the storage area is outside and is not provided with non-smoking or no- smoking signs.

An interview with staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all medical gas storage and use area requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the Hyperbaric Treatment Area is not provided with adequate non-smoking and no smoking signs on the outside of the area.

An interview with staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all medical gas storage requirements are being met. NFPA 101, 2000 Edition, para. 39.3.2, and NFPA 99, para 8.6.4.2.

The findings are:

During a tour of this facility with staff S1 and staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the medical gas storage room is not provided with non-smoking and no smoking signs.

An interview with staff S1 and staff M confirmed the findings.

Based on observations, testing, and staff interview, the facility failed to insure that all electrical wiring and equipment requirements were being met.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following electrical deficiencies were noted:

a. 8th floor, West Main stairwell, electrical junction box cover missing,
b. 6th floor, kitchenette, the receptacle near the sink is not a ground fault interceptor type,
c. 5th floor, coffee room, North Hall, the receptacle near the sink is not a ground fault interceptor type,
d. 4th floor, coffee room, Main, the receptacle near the sink is not a ground fault interceptor type,
e. 4th floor, electrical junction box cover missing in the ceiling above elevator #6,
f. 4th floor, Room #461, the receptacle near the sink is not a ground fault interceptor type.

An interview with staff S1 confirmed the findings.

Based on observations, testing, and staff interviews the facility failed to insure that all corridor walls meet the requirements.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following corridor wall deficiencies were noted:

a. 3rd floor Treatment Room, has a louver in the corridor wall,
b. 3rd floor, this floor is not provided with automatic sprinkler protection and the corridor wall is not properly sealed at the deck above,
c. 1st floor, across from the elevator, has a louver in the corridor wall,

An interview with staff M confirmed the findings.

Based on observations, testing and staff interviews, the facility failed to insure that all doors protecting corridor openings meet the requirements.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m., the following corridor door deficiencies were noted:

a. 6th floor, the corridor door to room #647 does not properly close and latch,
b 5th floor, the corridor doors to rooms #501, 502, 504, 505, 512, and 558 do not properly close and latch and have a gap at the top.

The findings were confirmed by staff interview.

Based on observations, testing, and staff interviews the facility failed to insure that all corridor opening requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010, between the hours of 9:00 a. m. - 4:30 p. m., the following corridor door deficiencies were noted:

a. 4th floor, Sleep Room, has a louver in the corridor door,
b. 3rd floor, Activity Room, corridor door has a second leaf that is not auto latching,
c. 3rd floor, Activity Room, corridor door is not self closing,
d. ground floor, dutch door top leaf is not auto latching.

An interview with staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all vertical openings meet the requirements.

The finding are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. and 4:30 p. m. the following vertical openings deficiencies were noted:

a. 9th floor, South Main stairwell has a steel I-beam penetration of a fire wall that is not properly protected,
b. 7th floor, Elevator #6, a steel I-beam penetration that is not properly protected,
c. 6th floor, Elevator #9, a steel I-beam penetration that is not properly protected,
d. 5th floor, Elevator #9, a steel I-beam penetration that is not properly protected.

The findings were confirmed by staff interview.

Based on observations, testing, and staff interviews the facility failed to insure that al vertical opening requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following vertical opening deficiencies were noted:

a. 4th floor South Stairwell has an unprotected steel I-beam in the wall,
b. 3rd floor Elevator 42 has an unsealed penetration above the ceiling,
c. 1st floor Stair C fire wall is not sealed at the deck above,

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that the stairwells meet all the enclosure requirements.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the 1st floor South Stair has a 12" duct penetration without a damper.

An interview with staff M confirmed the findings.

Based on observations and staff interview, the facility failed to insure that smoke barrier walls meet the requirements.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following smoke barrier deficiencies were noted:

a. the 1st floor shell space has part of the rated wall assembly removed,
b. the 1st floor Breast Center has an unsealed sprinkler pipe penetrating the fire wall,


An interview with staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that the smoke barrier walls provide a one half hour fire resistance rating.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. and 4:30 p. m. the following smoke barrier deficiencies were noted:

a. 9th floor, East Hall , unsealed wiring penetration in the fire wall above the smoke barrier doors,
b. 4th floor, smoke wall not properly sealed above the East and Main corridor doors.

The findings were confirmed by staff interview.

Based on observations, testing, and staff interviews the facility failed to insure that all smoke barrier wall requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following smoke barrier deficiencies were noted:

a. 4th floor smoke barrier has an unsealed penetrations above Fire Door #4007,
b. 3rd floor smoke barrier steel I-beam above Fire Door 3-009 is not properly protected,


An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews the facility failed to insure that all smoke barrier doors meet the requirements.

The finding are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the smoke barrier doors #1010 is not provided with a rabbet, bevel, or astragal and is not smoke tight.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all smoke barrier doors meet the requirements.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following smoke barrier door deficiencies were noted:

a. 7th floor, the smoke barrier doors on the North Hall do not properly close,
b 7th floor, the smoke barrier doors on the South Hall do not properly close,
c. 5th floor, the smoke barrier doors #63 do not properly close,
d. 4th floor, the smoke barrier doors #147 do not properly close,
e. 1st floor, smoke barrier doors #064 , 069, 072, and #73.

An interview with staff S1 confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all hazardous area requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that a 50 gal storage cart was located in the corridor near to door #HT-401.

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hour of 9:00 a. m.- 4:30 p. m. the hazardous chemical storage room is not properly sealed around a steel I-beam.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews the facility failed to insure that all hazardous areas are properly protected.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following hazardous area deficiencies were noted:
a. the kitchen's storage room door is a dutch door and the top leaf is not auto latching.
b. the kitchen's corridor doors are not auto latching.
c. 3rd floor, clean linen storage across from room C-314 has an accordion type door that is not rated. ( this floor is not provided with automatic sprinkler protection)

An interview with staff M confirms the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all hazardous areas were properly protected.

The findings are:

During a tour of the facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following deficiencies were noted:

a. the mechanical rooms on the ground floor have double fire doors and the second leaf is not automatic latching,
b. 1st floor file storage room Fire Door #1363 was blocked in an open position.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all hazardous areas were properly protected.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010, at 9:00 a. m. - 4:30 p. m., the following hazardous area deficiencies were noted:

a. 4th floor, Fire Door #153d does not properly close and latch,
b. 3rd floor, unsealed penetration above Fire Door K-3,
c. 2nd floor, there is a gap between the double doors, Fire Doors #441,
d. 2nd floor, Fire Door #371 does not properly close and latch,
e. 2nd floor, Fire Door #370 , was blocked open,
f. 1st floor, Fire Door #462, does not properly close and latch,
g. Basement, Fire Door #477 is on hold open devices and is not provided with smoke detection within 5 feet,
h. Basement, Fire Door #483A is not self closing.

An interview with staff S1 confirmed the findings.

Based on observations, testing, staff interviews the facility failed to insure that all hazardous area requirements are being met. NFPA 99.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following hazardous area deficiencies were noted:

a. the 2hr fire wall separating the Hyperbaric Treatment Area from the remainder of the building has unsealed wiring penetrations,
b. the 2hr fire wall has a non- rated fire extinguisher cabinet penetrating and is not properly protected,
c. the double fire doors in the 2hr fire wall have a second leaf that is not auto-latching.

An interview with staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all stairway requirements are being met. NFPA 101, 2000 Edition, para. 39.2.2.3.1.

The findings are:

During the tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following stair deficiencies were noted:

a. The guard rails are not at least 42" in height,
b. There are spaces in the guard rails that a 4 inch sphere can pass through.

An interview with staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all exit requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following stairwell guardrails deficiencies were noted:

a. the stairwell guardrails are not at least 42 " in height,
b. the guardrails have spaces that a 4 inch sphere can pass through.

An interview with staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all exits and egress requirements are being met.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. , the following stairwell deficiencies were noted:

a. some of the guardrails are not at least 42 inches in height,
b. the guardrails have spaces that a 4 inch sphere can pass through.

An interview staff S1 confirmed the findings.

Based on observations, testing and staff interviews, the facility failed to insure that all stairway requirements are being met. NFPA 101, 2000 Edition, para. 39.2.2.3.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following stairway deficiencies were noted:

a. the guard rails are not at least 42 inches in height,
b. the guard rails have spaces that a 4 inch sphere can pass through.

An interview with staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all exits were accessible at all times. NFPA 101, 2000 Edition, para. 39.2.7.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the exit ramp at the main entrance was not provided with a handrail on both sides.

An interview with staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all egress requirements are being met. NFPA 101, 2000 Edition, para. 39.2.7.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010, between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the exit ramps are not provided with handrails on both sides.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that the exits were accessible at all times.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the delayed egress mechanism on the 1st floor South Stair exit door did not open after 15 seconds.

An interview with staff M confirmed the findings.

Based on observations, testing and staff interviews, the facility failed to insure that all emergency lighting requirements are met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p.m. revealed that the emergency lighting does not provide illumination on all outside exits.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews the facility failed to insure that all emergency lighting requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that not all exits were provided with emergency lighting.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all emergency lighting requirements are being met. NFPA 101, 2000 Edition, para. 39.2.9.1.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010, between the hours of 9:00 a. m. and 4:30 p. m. it was noted that not all exits were provided with emergency lighting.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all emergency lighting requirements are being met. NFPA 101, 2000 Edition, para. 39.2.9.1.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following emergency lighting deficiencies were noted:

a. the emergency lighting units in the corridors would not work properly,
b. there is no emergency lighting provided for all exits.

An interview with staff M confirmed the requirements.

Based on observations, testing, and staff interviews, the facility failed to insure that all emergency lighting requirements are being met. NFPA 101, 2000 Edition, para. 39.2.9.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010, between the hours of 9:00 a. m. - 4:30 p. m. it was noted that emergency lighting is not provided in all areas.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all emergency lighting requirements are being met. NFPA 101, 2000 Edition, para. 39.2.9.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following emergency lighting deficiencies were noted:

a. no emergency lighting provided in the treatment or exam areas of the building,
c. no emergency lighting provided at all exits.

An interview with staff S1 confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all exits are provided with emergency illumination.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that all exits were not provided with emergency lighting.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all exit and directional sign requirements are being met. NFPA 101, 2000 Edition, para. 39.2.10.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 it was noted that the exit sign located near the Appointment Desk was not illuminated.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all exit and directional sign requirements are being met. NFPA 101, 2000 Edition, para. 39.2.10.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th between the hours of 9:00 a. m. - 4:30 p. m. it was noted that exit signs #331EL03 and 331EL06 were not properly illuminated.

An interview with staff S1 confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all exit and directional signs meet the requirements. NFPA 101, 2000 Edition, 39.2.10.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 it was noted that some of the exit and directional signs were not illuminated at the time of this inspection.

An interview with staff M confirmed the findings.

Based on observations, records review, and staff interviews, the facility failed to insure that all emergency plan and fire drills meet the requirements.

The findings are:

During a tour of this facility with staff S1 and staff M on May 3rd thru May 7th, 2010, between the hours of 9:00 a. m. - 4:30 p. m., it was noted that the fire drills were not being held at unexpected times under varying conditions on all shifts.

An interview with staff S1 and staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all fire alarm requirements are being met. NFPA 101, 2000 Edition, para. 39.3.4.1 and 39.3.4.2.

The findings are:

During a tour of this facility with staff S1 and staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following fire alarm deficiencies were noted:

a. The fire alarm pull station is not located near the main entrance/exit,
b. a smoke detector in the corridor is located too close to an HVAC register,
c. a smoke detector in the clean linen storage room is located too close to an HVAC register.

An interview with staff S1 and staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all fire alarm system requirements are being met. NFPA 101, 2000 Edition, para. 39.3.4.1.


The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010, between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the fire alarm panel is showing a trouble signal.

An interview with staff S1 confirmed the findings.

Based on observations, records review, and staff interviews, that facility failed to insure that all fire alarm system requirements were being met.

The findings are:

During a tour of this facility with staff S1 and staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following fire alarm deficiencies were noted:

a. 7th floor Room M-707, the smoke detector is located too close to an HVAC register,
b. 1st floor, Mechanical room, West Tower Annex, the smoke detectors area located greater than 12" from the ceiling,
c. Basement, Main Mechanical room, the smoke and heat detectors are located greater than 12" from the ceiling,
d. Basement, Main Corridor, the smoke detectors are located greater than 12" from the ceiling,
e. A review of the annual fire alarm system test documents revealed that several smoke detectors failed and no corrective action was noted, (see page 62 of the test documents).
f. A review of the annual fire alarm system test documents revealed that the fire door hold open device testing information was not dated,
g. A review of the annual fire alarm system test documents revealed that the smoke and fire damper testing does not include all equipment.

An interview with staff S1 and staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all smoke detector requirements are being met. NFPA 101. 2000 Edition. para. 39.3.4.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the smoke detector #103 is located too close to an HVAC register.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interview the facility failed to insure that all smoke detectors meet the requirements. NFPA 101, 2000 Edition, para. 39.3.4.1.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following smoke detector deficiencies were noted:

a. 1st floor corridor smoke detector located too close to an HVAC register,
b. the smoke detector near the Appointment Desk is located too close to the HVAC register,

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews the facility failed to insure that all smoke detector requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following smoke detector deficiencies were noted:

a. 4th floor, smoke detector outside of the elevator is located too close to a HVAC register,
b. 3rd floor, smoke detector outside of room #305 is located too close to a HVAC register,
c. The Bridge to the Main Hospital, the 2 hour fire doors are not provided with smoke detectors within 5 feet of the doors,

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all smoke detector requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following smoke detector deficiencies were noted:

a. the smoke detector in the soiled utility room #H-641 is located too close to the HVAC register,
b. the smoke detector in room #H-467 is located too close to the HVAC register,
c. the smoke detector located near the main fire alarm panel in the foyer is located too close to the HVAC register.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all smoke detector requirements are being met. NFPA 101, 2000 Edition, para. 39.3.4.1.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the smoke detector in the corridor is located too close to the HVAC register.

An interview with staff M confirmed the requirements.

Based on observations, testing, and staff interviews, the facility failed to insure that all smoke detectors meet the requirements.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following smoke detector deficiencies were noted:

a. The smoke detector located in the 1st floor Cancer Life Waiting room is located too close to the HVAC register.
b. The smoke detector located in the 2nd floor sterile supply closet is located too close to the HVAC register,
c. 1st floor smoke detector in the corridor outside the file storage room is located too close to the HVAC register.

An interview with staff M confirmed the findings.

Based on observations, records review, and staff interview, the facility failed to insure that all automatic sprinkler system requirements are being met.

The findings are:

During a tour of this facility with staff S1 and staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following sprinkler system deficiencies were noted:

a. 2nd floor, Mechanical room #2, South, the ductwork on HVAC unit #66 is wider than 48" without adequate sprinkler coverage beneath,
b. 1st floor, the Lab, the sprinkler heads are blocked by equipment and cabinets,
c. 1st floor, Blood Storage Cooler is not provided with sprinkler protection,
d. Basement, sprinkler eschutcheon plates missing in Environmental Services,
e. Basement, sprinkler system does not cover the entire Communication Storage room,
f. A review of the sprinkler system's annual test documents revealed that the test does not include the static and residual pressures,
g. Not all sprinkler valves are identified as to the areas covered throughout the building.

An interview with staff S1 and staff M confirmed the findings.

Based on observations, records reviews and staff interviews the facility failed to insure that all sprinkler system requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the pressure gauges on the sprinkler system have not been tested in the past 5 years.

An interview with staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all portable fire extinguisher requirements were being met.

The findings are:

During a tour of this facility on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the type K fire extinguisher was mounted farther than 5 feet from the automatic fire extinguishing system manual pull in the kitchen.

An interview with staff M confirms the findings.

Based on observations, records review, and staff interview, the facility failed to insure that all fire extinguisher requirements are being met.

The findings are:

During a tour of this facility with staff S1 and staff M on May 3rd thru May 7th, 2010 during the hours of 9:00 a. .m. - 4:30 p. m. , the annual service records for the portable fire extinguishers has some units listed that were not found or tested with no explanation.

An interview with staff S1 and staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all heating, ventilation, and air-conditioning requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. and 4:30 p. m. it was noted that the ground floor Patient Access office is not provided with an HVAC return duct system.

An interview with staff M confirms the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all cooking facility requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the kitchen's range hood has combustible ceiling tile adjacent to it.

An interview with staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all laundry chute requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd the May 7th, 2010, between the hours of 9:00 a. m - 4:30 p. m. it was noted that the linen chute's fire damper was blocked by excess linens.

An interview with staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that the medical gas storage areas meet all requirements.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010, between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the full and empty medical gas cylinders were not stored separately in properly identified areas.

An interview with staff M confirmed the findings.

Based on observations, testing, and staff interviews, the facility failed to insure that all medical gas storage requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following medical gas storage area deficiencies were noted:

a. the storage closet is not provided with a powered vent to the outside,
b. the storage area is not properly marked with non-smoking and no smoking signs.

An interview with staff M confirmed the requirements.

Based on observations and staff interviews, the facility failed to insure that all medical gas system requirements are being met.

The finding are:

During a tour of this facility with staff M on May 3rd thru May 7th between the hour of 9:00 a. m. - 4:30 p. m. the following medical gas system deficiencies were noted:

a. no fire extinguisher provided for the med. gas bulk storage area,
b. the storage area is outside and is not provided with non-smoking or no- smoking signs.

An interview with staff M confirmed the findings.

Based on observations and staff interviews the facility failed to insure that all medical gas storage and use area requirements are being met.

The findings are:

During a tour of this facility with staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the Hyperbaric Treatment Area is not provided with adequate non-smoking and no smoking signs on the outside of the area.

An interview with staff M confirmed the findings.

Based on observations and staff interviews, the facility failed to insure that all medical gas storage requirements are being met. NFPA 101, 2000 Edition, para. 39.3.2, and NFPA 99, para 8.6.4.2.

The findings are:

During a tour of this facility with staff S1 and staff M on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. it was noted that the medical gas storage room is not provided with non-smoking and no smoking signs.

An interview with staff S1 and staff M confirmed the findings.

Based on observations, testing, and staff interview, the facility failed to insure that all electrical wiring and equipment requirements were being met.

The findings are:

During a tour of this facility with staff S1 on May 3rd thru May 7th, 2010 between the hours of 9:00 a. m. - 4:30 p. m. the following electrical deficiencies were noted:

a. 8th floor, West Main stairwell, electrical junction box cover missing,
b. 6th floor, kitchenette, the receptacle near the sink is not a ground fault interceptor type,
c. 5th floor, coffee room, North Hall, the receptacle near the sink is not a ground fault interceptor type,
d. 4th floor, coffee room, Main, the receptacle near the sink is not a ground fault interceptor type,
e. 4th floor, electrical junction box cover missing in the ceiling above elevator #6,
f. 4th floor, Room #461, the receptacle near the sink is not a ground fault interceptor type.

An interview with staff S1 confirmed the findings.