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Based on observation and staff interviews, it was determined throughout this survey that the facility staff failed to insure that ceilings and partitions separating areas of the building were able to resist the passage of smoke thereby creating an unsafe condition.

The findings include:

1) At approximately 1055 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that the "Civista Imaging Echo Office" on the 3rd floor of the "Old Building" there are holes in the partitions within this room. These holes are in an old bathroom in this space.

2) At approximately 1100 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that in the IT Closet on the 3rd floor outside the ICU there are missing ceiling tiles. The missing ceiling tiles would allow the passage of smoke into other spaces along the corridor.

3) At approximately 1135 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Engineering Break Room which connects the Boiler Room and an Air Handling Unit Room on the ground floor there are missing ceiling tiles. The missing ceiling tiles would allow the passage of smoke into other spaces along the corridor. Ceiling tiles in this room must be installed to allow the automatic sprinkler system to function as designed.

4) At approximately 1310 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Storage Room next to Exam Room 35 on the ground floor the partitions (3 of 4) do not extend to the floor assembly above as required. In addition, there are missing ceiling tiles. The lack of partition separation and the missing ceiling tiles would allow the passage of smoke into other spaces along the corridor.

Failure to properly separate use areas from other areas of the building has the potential to allow smoke and fire spread and to promote harm to occupants of the building in the event of a fire.

Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining hazardous areas as required.

1) During the initial survey on November 1, 2011 at approximately 1155 hours it was observed and confirmed through interview with the Engineering Manager that in the Boiler Room on the Ground Floor there was combustible storage on top of the air handling unit(s) consisting of cardboard boxes of paper records and files. This combustible storage was above the level of the existing automatic sprinklers and is not permitted within the boiler room.

2) During the initial survey on November 1, 2011 at approximately 1245 hours it was observed and confirmed through interview with the Engineering Manager that in the Laundry Storage Room on the Ground Floor there was combustible items consisting of boxes of disposable gowns, masks, paper goods, plastic wrapped lined carts, and empty cardboard boxes. This combustible goods storage room, greater than fifty (50) square feet in area lacked a self-closing device on the door to the corridor.

All hazardous areas must be maintained in accordance with all requirements of NFPA 101. This has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based on observation of the physical environment and interviews with the facility staff, it was determined that the facility staff failed to provide as safe an environment as possible not having all stairways properly identified thereby creating an unsafe condition.

The findings include:

Throughout the initial survey on October 31 and November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that Exit Stairways spanning five or more stories (Ground Floor, 1,2, 3, and Roof) within the facility do not display proper stair identification signs to comply with this Code. 7.2.2.5.4

Failure to maintain the exits, stairways, and exit passageways as required by the Code has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interviews with the facility staff, it was determined that the facility staff failed to provide as safe an environment as possible by not maintaining exits as required.

The findings include:

1) At approximately 1220 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that the West Mechanical Room on the Ground Floor the means of egress door to the exterior public way was stuck closed.

2) At approximately 1230 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that the Main Entrance Door to the hospital, outer sliding door assembly, on the 1st Floor utilizes a powered door opener. This door assembly is equipped with a single cylinder dead bolt lock mechanism with a "thumb screw" latch on the interior of the door. The door assembly is posted with signs that state "In Emergency, Push To Open". When closed and locked these doors do not open when "Pushed" as instructed.

These conditions do not allow for the full and instant use of the means of egress doors when closed and/or locked thereby promoting the potential for harm to occupants of the facility in the event of a fire or other emergency.

Based on observation of the physical environment and interviews with the facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not ensuring that the full width of the aisles and corridors serving as exit access are clear and are unobstructed as required.

The findings include:

During the initial survey on November,1 2011 at approximately 12 hours, it was observed and confirmed through interview with the Engineering Manager that the West Mechanical \Corridor on the Ground Floor was obstructed to less than the full width as required. The obstructions included four (4) laundry carts and one (1) trash cart. This eight (8) feet wide corridor was obstructed to less than four (4) feet.

The reduced width of the corridors and obstructed access to exits has the potential to promote harm to occupants of the facility in the event of an emergency.

Based on observation of the physical environment and interviews with the facility staff, it was determined that the facility staff has failed to provide as safe an environment as possible by not installing a heat or smoke detector in the area of the Fire Alarm System control panel as required.

The findings include:

At approximately 1215 hours during the initial survey on November 1, 2011 it was observed and confirmed with the Engineering Manager that there was no smoke detector in the Ground Floor Fire Alarm Panel Room. This room houses a eight (8) fire alarm system panels and the room is not normally occupied.

NFPA 72 (1999 Edition as per CMS) 1-5.6 - Protection of Fire Alarm Control Units - In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted. However, areas not suitable for smoke detectors are most often not suitable for a fire alarm system control unit.

Note: Detectors protecting the Fire Alarm Control Panel must be wired directly to the fire alarm system. Battery operated detectors are not permitted.

The lack of smoke or heat detection in this room has the potential to promote harm to occupants of the building in the event of a fire occurring in this area.

Based on observation of the physical environment and interview with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not having a sprinkler system installed in accordance with NFPA 13 to provide complete coverage for all portions of the building.

The findings include:

1) During the initial survey at approximately 1150 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Engineering Break Room Bathroom there is no automatic sprinkler coverage.

2) During the initial survey at approximately 1200 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Exit Stairway from the Boiler Room (#4) there is no automatic sprinkler coverage at the lowest level as required.

3) During the initial survey at approximately 1210 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that in the H.I.M. Coding Manager Office there is no automatic sprinkler coverage as required.

4) During the initial survey at approximately 1220 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Paint Storage Room on the Ground Floor the automatic sprinkler coverage is installed below the height of items stored in the room. The automatic sprinkler heads must be installed within 12 inches of the ceiling within the room as required (Currently the A/S heads are approximately six (6) feet from the ceiling).

Failure to provide complete automatic sprinkler coverage to all parts of the building as required has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment, review of the facility's records, and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the automatic sprinkler and standpipe system as required.

The findings include:

1) Throughout the initial survey on October 31 and November 1, 2011 it was determined through observation of the physical environment and confirmed through interview with the Engineering Manager that the standpipe system in the facility has not been tested and maintained at proper intervals in accordance with NFPA 14 and NFPA 25 as required. Specifically, the standpipe system hose valves in the corridor standpipe cabinets have not been tested and maintained as required. Also, these hose valves have been disabled by the removal of the appropriate fire hose connection fittings and the placement of 1 1/2" and 2 1/2" plugs in the discharge openings.

Some locations where these standpipe valves with plugs installed are located include:
a. 3rd floor Old Building, Outside of ICU
b. 2nd floor Old Building, @ 2N
c. 2nd floor Old Building, @ 2E
d. 1st floor Old Building @ 1E (2 valves by Executive Office, Admin. Hall)
e. Ground floor by Mail Room
f. Ground floor by Workshop

The failure to maintain the automatic sprinkler and standpipe systems as required could lead to improper operation of the systems in the event of an emergency thereby promoting harm to occupants of the facility.

NFPA 14, Standard for the Installation of Standpipe, Private Hydrant, and Hose Systems, 2000 edition.

NFPA 25, Standard for Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, 1998 edition.

Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not enforcing the facility smoking policy and maintaining a hazard free non-smoking area.

The findings include:

During the initial survey on November 1, 2011 it was observed at approximately 11 hrs that in the "Healing Garden" there was evidence that numerous cigarette butts (in excess of 12) had been discarded in the area and the mulched flower beds. Facility staff advised that this is a non-smoking campus. Signs are conspicuously posted indicating same. As such, there are no ashtrays provided in this area.

Smoking in this area under the current procedures could lead to hazardous conditions. Guests and employees of the facility must be reminded and monitored to enforce the non-smoking policy of the facility. Failure to do so has the potential to promote harm to residents of the facility.

Based on observation of the physical environment and staff interviews, it was determined that the facility staff failed to provide as safe an environment as possible by allowing non-compliant portable electric portable space heating devices in the facility.

The findings include:

1) At approximately 1115 hours on October 31, 2011 during this survey it was observed and confirmed through an interview with the Engineering Manager that a portable electric space heater of the "glowing coil" type was in the Infection Prevention Office on the 3rd floor "Old Building". This space heater was removed from the building immediately as directed by this surveyor.

2) At approximately 1345 hours on October 31, 2011 during this survey it was observed and confirmed through interview with the Engineering Manager that in the 2E Employee Lounge of the "Old" building there was a portable electric space heater of the "glowing coil" type. This space heater was removed from the building immediately as directed by this surveyor.

3) At approximately 1245 hours on November 1, 2011 during this survey it was observed and confirmed through interview with the Engineering Manager that in the Mammography Exam Room on the Ground Floor there was a portable electric space heater of the "glowing coil" type in use in a patient treatment area. There was also a ceramic element portable electric space heater in use in this room. The "glowing coil" space heater was removed from the building immediately as directed by this surveyor. No portable electric space heaters are permitted in patient treatment areas.

The use of these portable electric space heaters has the potential to promote harm to occupants of the facility.

Based on observation of the physical environment and interview with the facility staff it was determined that the facility failed to maintain as safe an environment as possible by not ensuring that all means of egress remained free of obstructions to instant use as required.

The findings include:

During the initial survey on November,1 2011 at approximately 1200 hours, it was observed and confirmed through interview with the Engineering Manager that the West Mechanical Corridor on the Ground Floor was obstructed to less than the full width as required. The obstructions included four (4) laundry carts and one (1) trash cart. This eight (8) feet wide corridor was obstructed to less than four (4) feet.

The obstruction of any means of egress component to less than full width for immediate use in an emergency has the potential to promote harm to occupants of the facility in the event of a fire or other emergency.

Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining trash receptacles in approved hazardous areas as required.

During the initial survey on November 1, 2011 at approximately 1225 hours it was observed and confirmed through interview with the Engineering Manager that in the West Mechanical Corridor on the Ground Floor there were two trash collection receptacles exceeding 32 gallon capacity containing cardboard boxes and other trash. This combustible storage was left stored in the exit corridor not attended.

All hazardous and combustible trash must be maintained in accordance with all requirements of NFPA 101. This has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based on observation of the physical environment and interview with facility staff it was determined that the facility failed to provide a safe and hazard free environment by having non-compliant electrical applications.

The findings include:

1) During the initial survey at approximately 1045 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that in the ABG Lab on the 3rd floor of the "Old" building there are 120 VAC wall receptacles within 6 feet of a sink which are not Ground Fault Circuit Interrupter (GFCI) protected.

2) During the initial survey at approximately 1115 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Infection Prevention Office on the 3rd floor "Old Building" there was a microwave oven, coffee maker and refrigerator powered by a 15 amp rated strip outlet extension cord being used in a permanent, non-compliant manner.

3) During the initial survey at approximately 1345 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that in the 2E Employee Lounge of the "Old" building there are 120 VAC wall receptacles within 6 feet of a sink which are not Ground Fault Circuit Interrupter (GFCI) protected.

4) During the initial survey at approximately 1400 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Education Conference Room on the 2nd floor "Old Building" there was a coffee maker powered by a 15 amp rated strip outlet extension cord being used in a permanent, non-compliant manner.

5) During the initial survey at approximately 1410 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Bio Medical Office on the 1st floor there are 120 VAC wall receptacles within 6 feet of a sink which are not Ground Fault Circuit Interrupter (GFCI) protected.

6) During the initial survey at approximately 1450 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Communications Office on the 1st floor there was a microwave oven and refrigerator powered by a 15 amp rated strip outlet extension cord being used in a permanent, non-compliant manner.

7) During the initial survey at approximately 1455 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Manager-Medical Staff Services Office on the 1st floor there was a portable electric space heater and three other devices plugged into a 15 amp rated strip outlet which was plugged into another 15 amp rated strip with one other device which was plugged into the wall outlet in an unsafe, permanent, non-compliant manner.

8) During the initial survey at approximately 1125 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Engineering Break Room on the Ground Floor there were two coffee makers and two microwave ovens plugged into a four outlet receptacle box which was connected to a wall outlet by means of temporary wiring in an unsafe, permanent, non-compliant manner. This wall outlet also supplies electric power to a nine (9) outlet strip which powers a refrigerator.

The failure to install GFCI protected outlets within 6 feet of a sink or other wet areas as required has the potential to promote harm to occupants of the facility.

The use of strip outlets and other temporary wiring is not in compliance with NFPA 70, National Electrical Code, and has the potential to promote harm to occupants of the building.

Based on observation and staff interviews, it was determined throughout this survey that the facility staff failed to insure that ceilings and partitions separating areas of the building were able to resist the passage of smoke thereby creating an unsafe condition.

The findings include:

1) At approximately 1055 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that the "Civista Imaging Echo Office" on the 3rd floor of the "Old Building" there are holes in the partitions within this room. These holes are in an old bathroom in this space.

2) At approximately 1100 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that in the IT Closet on the 3rd floor outside the ICU there are missing ceiling tiles. The missing ceiling tiles would allow the passage of smoke into other spaces along the corridor.

3) At approximately 1135 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Engineering Break Room which connects the Boiler Room and an Air Handling Unit Room on the ground floor there are missing ceiling tiles. The missing ceiling tiles would allow the passage of smoke into other spaces along the corridor. Ceiling tiles in this room must be installed to allow the automatic sprinkler system to function as designed.

4) At approximately 1310 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Storage Room next to Exam Room 35 on the ground floor the partitions (3 of 4) do not extend to the floor assembly above as required. In addition, there are missing ceiling tiles. The lack of partition separation and the missing ceiling tiles would allow the passage of smoke into other spaces along the corridor.

Failure to properly separate use areas from other areas of the building has the potential to allow smoke and fire spread and to promote harm to occupants of the building in the event of a fire.

Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining hazardous areas as required.

1) During the initial survey on November 1, 2011 at approximately 1155 hours it was observed and confirmed through interview with the Engineering Manager that in the Boiler Room on the Ground Floor there was combustible storage on top of the air handling unit(s) consisting of cardboard boxes of paper records and files. This combustible storage was above the level of the existing automatic sprinklers and is not permitted within the boiler room.

2) During the initial survey on November 1, 2011 at approximately 1245 hours it was observed and confirmed through interview with the Engineering Manager that in the Laundry Storage Room on the Ground Floor there was combustible items consisting of boxes of disposable gowns, masks, paper goods, plastic wrapped lined carts, and empty cardboard boxes. This combustible goods storage room, greater than fifty (50) square feet in area lacked a self-closing device on the door to the corridor.

All hazardous areas must be maintained in accordance with all requirements of NFPA 101. This has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based on observation of the physical environment and interviews with the facility staff, it was determined that the facility staff failed to provide as safe an environment as possible not having all stairways properly identified thereby creating an unsafe condition.

The findings include:

Throughout the initial survey on October 31 and November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that Exit Stairways spanning five or more stories (Ground Floor, 1,2, 3, and Roof) within the facility do not display proper stair identification signs to comply with this Code. 7.2.2.5.4

Failure to maintain the exits, stairways, and exit passageways as required by the Code has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interviews with the facility staff, it was determined that the facility staff failed to provide as safe an environment as possible by not maintaining exits as required.

The findings include:

1) At approximately 1220 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that the West Mechanical Room on the Ground Floor the means of egress door to the exterior public way was stuck closed.

2) At approximately 1230 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that the Main Entrance Door to the hospital, outer sliding door assembly, on the 1st Floor utilizes a powered door opener. This door assembly is equipped with a single cylinder dead bolt lock mechanism with a "thumb screw" latch on the interior of the door. The door assembly is posted with signs that state "In Emergency, Push To Open". When closed and locked these doors do not open when "Pushed" as instructed.

These conditions do not allow for the full and instant use of the means of egress doors when closed and/or locked thereby promoting the potential for harm to occupants of the facility in the event of a fire or other emergency.

Based on observation of the physical environment and interviews with the facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not ensuring that the full width of the aisles and corridors serving as exit access are clear and are unobstructed as required.

The findings include:

During the initial survey on November,1 2011 at approximately 12 hours, it was observed and confirmed through interview with the Engineering Manager that the West Mechanical \Corridor on the Ground Floor was obstructed to less than the full width as required. The obstructions included four (4) laundry carts and one (1) trash cart. This eight (8) feet wide corridor was obstructed to less than four (4) feet.

The reduced width of the corridors and obstructed access to exits has the potential to promote harm to occupants of the facility in the event of an emergency.

Based on observation of the physical environment and interviews with the facility staff, it was determined that the facility staff has failed to provide as safe an environment as possible by not installing a heat or smoke detector in the area of the Fire Alarm System control panel as required.

The findings include:

At approximately 1215 hours during the initial survey on November 1, 2011 it was observed and confirmed with the Engineering Manager that there was no smoke detector in the Ground Floor Fire Alarm Panel Room. This room houses a eight (8) fire alarm system panels and the room is not normally occupied.

NFPA 72 (1999 Edition as per CMS) 1-5.6 - Protection of Fire Alarm Control Units - In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted. However, areas not suitable for smoke detectors are most often not suitable for a fire alarm system control unit.

Note: Detectors protecting the Fire Alarm Control Panel must be wired directly to the fire alarm system. Battery operated detectors are not permitted.

The lack of smoke or heat detection in this room has the potential to promote harm to occupants of the building in the event of a fire occurring in this area.

Based on observation of the physical environment and interview with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not having a sprinkler system installed in accordance with NFPA 13 to provide complete coverage for all portions of the building.

The findings include:

1) During the initial survey at approximately 1150 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Engineering Break Room Bathroom there is no automatic sprinkler coverage.

2) During the initial survey at approximately 1200 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Exit Stairway from the Boiler Room (#4) there is no automatic sprinkler coverage at the lowest level as required.

3) During the initial survey at approximately 1210 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that in the H.I.M. Coding Manager Office there is no automatic sprinkler coverage as required.

4) During the initial survey at approximately 1220 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Paint Storage Room on the Ground Floor the automatic sprinkler coverage is installed below the height of items stored in the room. The automatic sprinkler heads must be installed within 12 inches of the ceiling within the room as required (Currently the A/S heads are approximately six (6) feet from the ceiling).

Failure to provide complete automatic sprinkler coverage to all parts of the building as required has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment, review of the facility's records, and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the automatic sprinkler and standpipe system as required.

The findings include:

1) Throughout the initial survey on October 31 and November 1, 2011 it was determined through observation of the physical environment and confirmed through interview with the Engineering Manager that the standpipe system in the facility has not been tested and maintained at proper intervals in accordance with NFPA 14 and NFPA 25 as required. Specifically, the standpipe system hose valves in the corridor standpipe cabinets have not been tested and maintained as required. Also, these hose valves have been disabled by the removal of the appropriate fire hose connection fittings and the placement of 1 1/2" and 2 1/2" plugs in the discharge openings.

Some locations where these standpipe valves with plugs installed are located include:
a. 3rd floor Old Building, Outside of ICU
b. 2nd floor Old Building, @ 2N
c. 2nd floor Old Building, @ 2E
d. 1st floor Old Building @ 1E (2 valves by Executive Office, Admin. Hall)
e. Ground floor by Mail Room
f. Ground floor by Workshop

The failure to maintain the automatic sprinkler and standpipe systems as required could lead to improper operation of the systems in the event of an emergency thereby promoting harm to occupants of the facility.

NFPA 14, Standard for the Installation of Standpipe, Private Hydrant, and Hose Systems, 2000 edition.

NFPA 25, Standard for Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, 1998 edition.

Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not enforcing the facility smoking policy and maintaining a hazard free non-smoking area.

The findings include:

During the initial survey on November 1, 2011 it was observed at approximately 11 hrs that in the "Healing Garden" there was evidence that numerous cigarette butts (in excess of 12) had been discarded in the area and the mulched flower beds. Facility staff advised that this is a non-smoking campus. Signs are conspicuously posted indicating same. As such, there are no ashtrays provided in this area.

Smoking in this area under the current procedures could lead to hazardous conditions. Guests and employees of the facility must be reminded and monitored to enforce the non-smoking policy of the facility. Failure to do so has the potential to promote harm to residents of the facility.

Based on observation of the physical environment and staff interviews, it was determined that the facility staff failed to provide as safe an environment as possible by allowing non-compliant portable electric portable space heating devices in the facility.

The findings include:

1) At approximately 1115 hours on October 31, 2011 during this survey it was observed and confirmed through an interview with the Engineering Manager that a portable electric space heater of the "glowing coil" type was in the Infection Prevention Office on the 3rd floor "Old Building". This space heater was removed from the building immediately as directed by this surveyor.

2) At approximately 1345 hours on October 31, 2011 during this survey it was observed and confirmed through interview with the Engineering Manager that in the 2E Employee Lounge of the "Old" building there was a portable electric space heater of the "glowing coil" type. This space heater was removed from the building immediately as directed by this surveyor.

3) At approximately 1245 hours on November 1, 2011 during this survey it was observed and confirmed through interview with the Engineering Manager that in the Mammography Exam Room on the Ground Floor there was a portable electric space heater of the "glowing coil" type in use in a patient treatment area. There was also a ceramic element portable electric space heater in use in this room. The "glowing coil" space heater was removed from the building immediately as directed by this surveyor. No portable electric space heaters are permitted in patient treatment areas.

The use of these portable electric space heaters has the potential to promote harm to occupants of the facility.

Based on observation of the physical environment and interview with the facility staff it was determined that the facility failed to maintain as safe an environment as possible by not ensuring that all means of egress remained free of obstructions to instant use as required.

The findings include:

During the initial survey on November,1 2011 at approximately 1200 hours, it was observed and confirmed through interview with the Engineering Manager that the West Mechanical Corridor on the Ground Floor was obstructed to less than the full width as required. The obstructions included four (4) laundry carts and one (1) trash cart. This eight (8) feet wide corridor was obstructed to less than four (4) feet.

The obstruction of any means of egress component to less than full width for immediate use in an emergency has the potential to promote harm to occupants of the facility in the event of a fire or other emergency.

Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining trash receptacles in approved hazardous areas as required.

During the initial survey on November 1, 2011 at approximately 1225 hours it was observed and confirmed through interview with the Engineering Manager that in the West Mechanical Corridor on the Ground Floor there were two trash collection receptacles exceeding 32 gallon capacity containing cardboard boxes and other trash. This combustible storage was left stored in the exit corridor not attended.

All hazardous and combustible trash must be maintained in accordance with all requirements of NFPA 101. This has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based on observation of the physical environment and interview with facility staff it was determined that the facility failed to provide a safe and hazard free environment by having non-compliant electrical applications.

The findings include:

1) During the initial survey at approximately 1045 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that in the ABG Lab on the 3rd floor of the "Old" building there are 120 VAC wall receptacles within 6 feet of a sink which are not Ground Fault Circuit Interrupter (GFCI) protected.

2) During the initial survey at approximately 1115 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Infection Prevention Office on the 3rd floor "Old Building" there was a microwave oven, coffee maker and refrigerator powered by a 15 amp rated strip outlet extension cord being used in a permanent, non-compliant manner.

3) During the initial survey at approximately 1345 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that in the 2E Employee Lounge of the "Old" building there are 120 VAC wall receptacles within 6 feet of a sink which are not Ground Fault Circuit Interrupter (GFCI) protected.

4) During the initial survey at approximately 1400 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Education Conference Room on the 2nd floor "Old Building" there was a coffee maker powered by a 15 amp rated strip outlet extension cord being used in a permanent, non-compliant manner.

5) During the initial survey at approximately 1410 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Bio Medical Office on the 1st floor there are 120 VAC wall receptacles within 6 feet of a sink which are not Ground Fault Circuit Interrupter (GFCI) protected.

6) During the initial survey at approximately 1450 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Communications Office on the 1st floor there was a microwave oven and refrigerator powered by a 15 amp rated strip outlet extension cord being used in a permanent, non-compliant manner.

7) During the initial survey at approximately 1455 hours on October 31, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Manager-Medical Staff Services Office on the 1st floor there was a portable electric space heater and three other devices plugged into a 15 amp rated strip outlet which was plugged into another 15 amp rated strip with one other device which was plugged into the wall outlet in an unsafe, permanent, non-compliant manner.

8) During the initial survey at approximately 1125 hours on November 1, 2011 it was observed and confirmed through interview with the Engineering Manager that in the Engineering Break Room on the Ground Floor there were two coffee makers and two microwave ovens plugged into a four outlet receptacle box which was connected to a wall outlet by means of temporary wiring in an unsafe, permanent, non-compliant manner. This wall outlet also supplies electric power to a nine (9) outlet strip which powers a refrigerator.

The failure to install GFCI protected outlets within 6 feet of a sink or other wet areas as required has the potential to promote harm to occupants of the facility.

The use of strip outlets and other temporary wiring is not in compliance with NFPA 70, National Electrical Code, and has the potential to promote harm to occupants of the building.