HospitalInspections.org

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Based on observation and interview, the facility did not ensure that vertical electrical penetrations were properly sealed. Specific reference is made to ensuring the integrity of fire barrier walls that enclose Exit Staircases.

Findings:

a. On 05/11/16 at 9:24AM, an unsealed conduit penetration was noted in the 1-hour fire barrier wall that separates Exit Stair 2 from the "Rabbit Room" Storage Room. In addition, the door that separates this Storage Room from the Exit Stair was found to lack a required self-closing device.

b. On 05/11/16 at 9:28AM, an unsealed cable penetration, an unsealed conduit penetration, and an unsealed plumbing penetration were in the 1-hour fire barrier wall that separates Exit Stair 2 from the Rooftop Elevator Machine Room.

c. On 05/11/16 at 11:10AM, the Lower-Level Domestic Water Pump Room was found to not be completely separated from Exit Stair 20 by at least a 1-hour fire barrier wall.

As per concurrent interview with Staff G, the staff member acknowledged the above mentioned deficiencies and said that he will inform Hospital Administration of them.

NFPA 101-2000 Life Safety Code: 19.3.1, 8.2.3, 7.1.3.2
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Based on observation and interview, the facility failed to ensure that new hazardous areas that were greater than 100 square feet in size were protected by a sprinkler system and enclosed in 1-hour fire resistance rated construction. The requirements for sprinkler protection and fire resistive construction are to help suppress and contain a fire to the room of fire origin. Failure to seal all penetrations could result in smoke and other products of combustion escaping into patient areas.

Findings:

a. On 05/09/16 at 1:50PM, two (2) partially sealed plumbing penetrations were noted in a wall of Clean Utility Room 3046. The requirements for sprinkler protection and fire resistive construction are to help suppress and contain a fire to the room of fire origin. Failure to seal all penetrations could result in smoke and other products of combustion escaping into patient areas.

b. On 05/09/16 at 2:29PM, an unsealed duct penetration was noted in a wall in Clean Utility Room 1029.

As per concurrent interview with Staff G, the staff member acknowledged the above mentioned deficiency and said that he will inform facility Administration of it.

NFPA 101-2000 Life Safety Code: 18.3.2.1
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Based on observation and staff interview, the facility failed to ensure that hazardous areas were protected according to NFPA 101-2000 Life Safety Code.

Findings:

a. On 05/11/16 at 11:03AM, it was observed that the wall of the Old Film Storage Room at the Radiology Unit at the Basement of the building was not continuous to the ceiling to form a smoke resistive partition.

b. On 05/11/16 at 11:03AM, two (2) conduit penetrations were noted above the wall of the Old Film Storage Room.

c. On 05/10/16 at 11:15AM, it was observed that a Storage Room in the vicinity of the Central Plant Room on 1st Floor lacked a self-closing device on the door.

As per concurrent interview with Staff H, the staff member confirmed these findings and said he will inform the facility Administrator.

NFPA 101-2000 Life Safety Code 19.3.2.1
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Based on observation and interview, the facility failed to ensure that required automatic sprinkler systems were installed in accordance with the requirements found in NFPA 13, Standard for the Installation of Sprinkler Systems.

Findings:

a. On 05/09/16 at 1:12PM, it was noted that no automatic sprinkler protection was provided at the top of the shaft of Exit Stair 15 in the North Pavilion Building.

b. On 05/09/16 at 1:28PM, it was noted that no automatic sprinkler protection was provided at the top of the shaft of Exit Stair 16 in the North Pavilion Building.

As per concurrent interview with Staff G, the staff member acknowledged the above mentioned deficiencies and said that he will inform facility Administration of them.

NFPA 101-2000 Life Safety Code: 18.3.5.1, 9.7, NFPA 13-1999, Standard for the Installation of Sprinkler Systems: 5-13.3.2
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Based on observation and interview, the facility failed to ensure that required automatic sprinkler systems were installed in accordance with the requirements found in NFPA 13, Standard for the Installation of Sprinkler Systems.

Findings:

a. On 05/11/16 at 10:28AM, it was noted that no automatic sprinkler protection was provided in 3rd Floor Environmental Services Closet #3150.

b. On 05/11/16 at 10:55AM, it was noted that no automatic sprinkler protection was provided at the bottom of the shaft of Exit Stair 2 in the Lower-Level of the hospital building.

As per concurrent interview with Staff G, the staff member acknowledged the above mentioned deficiencies and said that he will inform facility Administration of them.

NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7, NFPA 13-1999, Standard for the Installation of Sprinkler Systems: 5-13.3.2
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Based on observation and staff interview, the facility failed to ensure that the automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically.

Findings:

a. On 05/09/16 at 2:23PM, it was observed that a sprinkler escutcheon cover plate was missing from a concealed sprinkler head in the Bathroom at the Outpatient Rehabilitation Unit located at Lower Level of the McGann Building.

b. On 05/11/16 at 11:14AM, a sprinkler pipe was noted to be resting directly on a large round waste pipe above the suspended ceiling of the Bathroom in the vicinity of the Old Film Storage Room in the Radiology Department.

As per concurrent interview with Staff H, the staff member confirmed these findings and said he will inform the facility Administrator.

NFPA 101-2000 Life Safety Code 19.7.6, 4.6.12, 9.7.5, NFPA 13, NFPA 25
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Based on observation, record review and staff interview, the facility failed to ensure that required monthly inspection of the wet chemical fire extinguishing system in the Kitchen was performed.

Findings:

On 05/09/16 at 10:10AM, the Monthly Inspection Tag of a manual actuator for the wet chemical fire extinguishment system in the Lower Level was found to not have been completed for the months of March and April, 2016.

As per concurrent interview with Staff G, the staff member acknowledged the above mentioned deficiency and said that he will inform facility administration of it.

NFPA 101-2000 Life Safety Code: 18.3.2.6, 9.2.3, NFPA 96-1998 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, NFPA 17, Standard for Dry Chemical Extinguishing Systems: 5-2.1
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Based on observation and staff interview, the facility failed to ensure that the integrity of the 2-hour combination smoke / fire barrier that separates the North Pavilion Building (a New Health Care Occupancy) from the Malloy Building (an existing health care occupancy was maintained.

Findings:

On 05/09/16 at 1:44PM, an unsealed cable pentation was noted in the 2-hour combination smoke / fire barrier wall (above the cross-corridor doors near Environmental Services Room 3047) that separates the 3rd Floor of the North Pavilion Building from the 3rd Floor of the Malloy Building.

As per concurrent interview with Staff G, the staff member acknowledged the above mentioned deficiency and said that he will inform facility Administration of it.

NFPA 101-2000 Life Safety Code: 18.3.7.3, 8.2.3

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1. Based on observation and staff interview, the facility failed to ensure that the automatic sprinkler system in the facility's Extension Clinic was continuously maintained in reliable operating condition and was inspected and tested periodically.

Findings:

On 05/12/16 at 10:34AM, it was noted that the spare sprinkler cabinet box in the Sprinkler Room of the facility's Extension Clinic located at 506 Stewart Avenue, Garden City, NY lacked the required special sprinkler wrench. The facility also had upright sprinkler heads in the facility but lacked spare sprinkler heads of this type in the spare cabinet as required.

As per concurrent interview with Staff H, the staff member confirmed these findings and said he will inform the facility Administrator.

NFPA 101-2000 Life Safety Code 19.7.6, 4.6.12, 9.7.5, NFPA 13, NFPA 25


2. Based on observation and staff interview, the facility failed to ensure that hazardous areas in the facility's Extension Clinic were properly protected accordance to NFPA 101-2000.

Findings:

On 05/12/16 at 10:50AM, it was observed that the door to the Closed File Cabinet Storage Room at the Extension Clinic located at 506 Stewart Avenue, Garden City, NY lacked a self-closing device.

As per concurrent interview with Staff H, the staff member confirmed this finding and said he will inform the facility Administrator.

NFPA 101-2000 Life Safety Code 38.3.2, 8.4


3. Based on document review and staff interview, the facility failed to ensure that Ground Fault Circuit Interrupter (GFCI) Receptacles in the facility's Extension Clinic were tested monthly according to Manufacturer's Instructions.

Findings:

On 05/12/16 at 11:30AM during document review, it was revealed that there were no records of the required monthly testing of the GFCIs at the Extension Clinic located at 506 Stewart Avenue, Garden City, NY.

As per a concurrent interview with Staff H, the staff member confirmed this finding and said he will inform the facility Administrator.


NFPA 101-2000 Life Safety Code: 38.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3


4. Based on observation and staff interview, the facility failed to maintain the integrity of the 2-hour fire barrier separating the MSK (the MSK Building is an existing business occupancy) Building and the McGann Building at the Lower Level.

Findings:

On 05/09/16 at 1:25PM, an unsealed cable penetration was observed above the ceiling of the 2-hour fire barrier directly above the ninety (90) minute double door at the Lower Level of the McGann Building and the MSK Building.

A concurrent interview with Staff H on 05/09/16 at 1:25PM confirmed this condition. The staff member said he will inform the facility Administrator.

NFPA 101-2000 Life Safety Code 8.2.3.2.4.2
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1. Based on observation and staff interview during the survey, the facility failed to ensure that all panelboard circuits and circuit modifications were legibly identified as to purpose or use on a Circuit Directory located on the face or inside of the panel doors in accordance with the Requirements of NFPA 70, National Electrical Code.

The findings include, but are not limited to, the following:

a. On 05/11/16 at 10:20AM, the review of the Panel Directory for Panel "LS-3" on the 3rd Floor of the facility revealed that the function of Circuits 2, 4, 5, 6, 8, 10, 12 and 14 were only identified as "EXISTING". The lack of information of the specific functions of these circuits could hamper facility staff and/or emergency responders if they have to try to shut off a malfunctioning circuit or circuits.

b. On 05/11/16 at 1:24PM, the Panel Directory of Panel "LP-G-ECB -A (LS)" in the Lower Level of the facility was noted to be missing. The lack of the Directory could hamper facility staff and/or emergency responders if they have to try to shut off a malfunctioning circuit or circuits

As per concurrent interview with the Staff G, the staff member acknowledged the above mentioned deficiencies and said that he will inform facility Administration of them.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 384-13


2. Based on observations and staff interview during the survey, the facility failed to ensure that electrical wiring was installed in a neat and workman like manner or maintained in good repair and that unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment were provided in accordance with the requirements of NFPA 70, National Electrical Code.

Findings:

a. On 05/11/16 at 10:30AM, unprotected openings due to five (5) missing circuit blanks (for Circuits #3, #4, #7, #9 and #10) were noted in Electrical Panel "LP-3-ECB" and an unprotected opening due to a missing circuit blank (for Circuit #2) was noted in Electrical Panel "LP-3-ELS" on the 3rd Floor of the facility.

b. On 05/11/16 at 1:34PM, an electrical junction box located above a suspended ceiling in a Lower-Level Corridor of the facility (vicinity of the OR Booking Office and Exit Stair #6) was noted be missing a cover plate on one (1) side of the box.

As per concurrent interview with Staff G, the staff member acknowledged the above mentioned deficiencies and said that he will inform facility Administration of them.

c. On 05/10/15 at 11:20AM, an open junction box was observed on the wall of the Central Plant Room.

d. On 05/10/15 at 1:31PM, an open junction box was noted above the suspended ceiling in the vicinity of Room 276.

e. On 5/11/16 at 11:21AM, an open electrical junction box was observed above the suspended ceiling of the Film Library Room in the Radiology Unit at the Basement of the building.

f. On 05/10/16 at 10:20AM, a broken duplex electrical receptacle was observed at the balcony of the Chapel.

g. On 05/11/16 at 10:10AM, a broken duplex electrical receptacle cover plate was observed by the corridor of Pulmonary Office in the vicinity of Room 417.

h. On 05/11/16 at 10:35AM, a broken duplex electrical receptacle cover plate was noted inside the Telephone Closet at the 3rd Floor Pain Management Unit.

i. On 05/11/16 at 2:00PM, a duplex electrical receptacle labeled EPL-ORCKT32 in between the corridor wall of Operating Rooms 7 and 8 was observed to be cracked.

As per concurrent interview with Staff H, the staff member confirmed these findings and said he will inform the facility Administrator.


3. Based on observation and staff interview, the facility failed to ensure that the electrical wiring and equipment were in accordance with the requirements of NFPA 70, National Electrical Code. Specific reference is made to the requirement to remove all temporary wiring and light fixtures immediately upon completion of construction.

Findings:

a. On 05/09/16 at 2:11PM, temporary wiring and lighting fixtures were observed above the suspended ceiling of the Radiation Oncology Unit in the Lower Level of the McGann Building.

b. On 05/10/16 at 11:25AM, temporary wiring and lighting fixtures were noted inside the Central Plant Room located at the 1st Floor of the existing building.

As per concurrent interview with Staff H, the staff member confirmed these findings and said he will inform the facility Administrator.


4. Based on observation, record review and staff interview, the facility failed to ensure that electrical equipment was used in accordance with its listing and that flexible wiring was not used as a substitute for the fixed wiring of a structure.

Findings:

On 05/09/16 at 1:45PM, two (2) serially connected relocatable power taps were noted at the Receptionist Area in the Outpatient Rehabilitation Unit. Relocatable power taps must be used in accordance with their listing.

On 05/11/16 at 10:45AM, it was noted that a window Air Conditioner (AC) Unit was connected directly into an extension cord in Staff Locker Room 3152 which is in violation of the facility's Policy and Procedure titled "Plant Operations Policy and Procedure Manual" last revised on 06/30/15.

As per concurrent interview with Staff H, the staff member confirmed these findings and said he will inform the facility Administrator.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3, 400-8

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Based on observation and interview, the facility did not ensure that vertical electrical penetrations were properly sealed. Specific reference is made to ensuring the integrity of fire barrier walls that enclose Exit Staircases.

Findings:

a. On 05/11/16 at 9:24AM, an unsealed conduit penetration was noted in the 1-hour fire barrier wall that separates Exit Stair 2 from the "Rabbit Room" Storage Room. In addition, the door that separates this Storage Room from the Exit Stair was found to lack a required self-closing device.

b. On 05/11/16 at 9:28AM, an unsealed cable penetration, an unsealed conduit penetration, and an unsealed plumbing penetration were in the 1-hour fire barrier wall that separates Exit Stair 2 from the Rooftop Elevator Machine Room.

c. On 05/11/16 at 11:10AM, the Lower-Level Domestic Water Pump Room was found to not be completely separated from Exit Stair 20 by at least a 1-hour fire barrier wall.

As per concurrent interview with Staff G, the staff member acknowledged the above mentioned deficiencies and said that he will inform Hospital Administration of them.

NFPA 101-2000 Life Safety Code: 19.3.1, 8.2.3, 7.1.3.2
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Based on observation and interview, the facility failed to ensure that new hazardous areas that were greater than 100 square feet in size were protected by a sprinkler system and enclosed in 1-hour fire resistance rated construction. The requirements for sprinkler protection and fire resistive construction are to help suppress and contain a fire to the room of fire origin. Failure to seal all penetrations could result in smoke and other products of combustion escaping into patient areas.

Findings:

a. On 05/09/16 at 1:50PM, two (2) partially sealed plumbing penetrations were noted in a wall of Clean Utility Room 3046. The requirements for sprinkler protection and fire resistive construction are to help suppress and contain a fire to the room of fire origin. Failure to seal all penetrations could result in smoke and other products of combustion escaping into patient areas.

b. On 05/09/16 at 2:29PM, an unsealed duct penetration was noted in a wall in Clean Utility Room 1029.

As per concurrent interview with Staff G, the staff member acknowledged the above mentioned deficiency and said that he will inform facility Administration of it.

NFPA 101-2000 Life Safety Code: 18.3.2.1
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Based on observation and staff interview, the facility failed to ensure that hazardous areas were protected according to NFPA 101-2000 Life Safety Code.

Findings:

a. On 05/11/16 at 11:03AM, it was observed that the wall of the Old Film Storage Room at the Radiology Unit at the Basement of the building was not continuous to the ceiling to form a smoke resistive partition.

b. On 05/11/16 at 11:03AM, two (2) conduit penetrations were noted above the wall of the Old Film Storage Room.

c. On 05/10/16 at 11:15AM, it was observed that a Storage Room in the vicinity of the Central Plant Room on 1st Floor lacked a self-closing device on the door.

As per concurrent interview with Staff H, the staff member confirmed these findings and said he will inform the facility Administrator.

NFPA 101-2000 Life Safety Code 19.3.2.1
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Based on observation and interview, the facility failed to ensure that required automatic sprinkler systems were installed in accordance with the requirements found in NFPA 13, Standard for the Installation of Sprinkler Systems.

Findings:

a. On 05/09/16 at 1:12PM, it was noted that no automatic sprinkler protection was provided at the top of the shaft of Exit Stair 15 in the North Pavilion Building.

b. On 05/09/16 at 1:28PM, it was noted that no automatic sprinkler protection was provided at the top of the shaft of Exit Stair 16 in the North Pavilion Building.

As per concurrent interview with Staff G, the staff member acknowledged the above mentioned deficiencies and said that he will inform facility Administration of them.

NFPA 101-2000 Life Safety Code: 18.3.5.1, 9.7, NFPA 13-1999, Standard for the Installation of Sprinkler Systems: 5-13.3.2
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Based on observation and interview, the facility failed to ensure that required automatic sprinkler systems were installed in accordance with the requirements found in NFPA 13, Standard for the Installation of Sprinkler Systems.

Findings:

a. On 05/11/16 at 10:28AM, it was noted that no automatic sprinkler protection was provided in 3rd Floor Environmental Services Closet #3150.

b. On 05/11/16 at 10:55AM, it was noted that no automatic sprinkler protection was provided at the bottom of the shaft of Exit Stair 2 in the Lower-Level of the hospital building.

As per concurrent interview with Staff G, the staff member acknowledged the above mentioned deficiencies and said that he will inform facility Administration of them.

NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7, NFPA 13-1999, Standard for the Installation of Sprinkler Systems: 5-13.3.2
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Based on observation and staff interview, the facility failed to ensure that the automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically.

Findings:

a. On 05/09/16 at 2:23PM, it was observed that a sprinkler escutcheon cover plate was missing from a concealed sprinkler head in the Bathroom at the Outpatient Rehabilitation Unit located at Lower Level of the McGann Building.

b. On 05/11/16 at 11:14AM, a sprinkler pipe was noted to be resting directly on a large round waste pipe above the suspended ceiling of the Bathroom in the vicinity of the Old Film Storage Room in the Radiology Department.

As per concurrent interview with Staff H, the staff member confirmed these findings and said he will inform the facility Administrator.

NFPA 101-2000 Life Safety Code 19.7.6, 4.6.12, 9.7.5, NFPA 13, NFPA 25
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Based on observation, record review and staff interview, the facility failed to ensure that required monthly inspection of the wet chemical fire extinguishing system in the Kitchen was performed.

Findings:

On 05/09/16 at 10:10AM, the Monthly Inspection Tag of a manual actuator for the wet chemical fire extinguishment system in the Lower Level was found to not have been completed for the months of March and April, 2016.

As per concurrent interview with Staff G, the staff member acknowledged the above mentioned deficiency and said that he will inform facility administration of it.

NFPA 101-2000 Life Safety Code: 18.3.2.6, 9.2.3, NFPA 96-1998 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, NFPA 17, Standard for Dry Chemical Extinguishing Systems: 5-2.1
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Based on observation and staff interview, the facility failed to ensure that the integrity of the 2-hour combination smoke / fire barrier that separates the North Pavilion Building (a New Health Care Occupancy) from the Malloy Building (an existing health care occupancy was maintained.

Findings:

On 05/09/16 at 1:44PM, an unsealed cable pentation was noted in the 2-hour combination smoke / fire barrier wall (above the cross-corridor doors near Environmental Services Room 3047) that separates the 3rd Floor of the North Pavilion Building from the 3rd Floor of the Malloy Building.

As per concurrent interview with Staff G, the staff member acknowledged the above mentioned deficiency and said that he will inform facility Administration of it.

NFPA 101-2000 Life Safety Code: 18.3.7.3, 8.2.3

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1. Based on observation and staff interview, the facility failed to ensure that the automatic sprinkler system in the facility's Extension Clinic was continuously maintained in reliable operating condition and was inspected and tested periodically.

Findings:

On 05/12/16 at 10:34AM, it was noted that the spare sprinkler cabinet box in the Sprinkler Room of the facility's Extension Clinic located at 506 Stewart Avenue, Garden City, NY lacked the required special sprinkler wrench. The facility also had upright sprinkler heads in the facility but lacked spare sprinkler heads of this type in the spare cabinet as required.

As per concurrent interview with Staff H, the staff member confirmed these findings and said he will inform the facility Administrator.

NFPA 101-2000 Life Safety Code 19.7.6, 4.6.12, 9.7.5, NFPA 13, NFPA 25


2. Based on observation and staff interview, the facility failed to ensure that hazardous areas in the facility's Extension Clinic were properly protected accordance to NFPA 101-2000.

Findings:

On 05/12/16 at 10:50AM, it was observed that the door to the Closed File Cabinet Storage Room at the Extension Clinic located at 506 Stewart Avenue, Garden City, NY lacked a self-closing device.

As per concurrent interview with Staff H, the staff member confirmed this finding and said he will inform the facility Administrator.

NFPA 101-2000 Life Safety Code 38.3.2, 8.4


3. Based on document review and staff interview, the facility failed to ensure that Ground Fault Circuit Interrupter (GFCI) Receptacles in the facility's Extension Clinic were tested monthly according to Manufacturer's Instructions.

Findings:

On 05/12/16 at 11:30AM during document review, it was revealed that there were no records of the required monthly testing of the GFCIs at the Extension Clinic located at 506 Stewart Avenue, Garden City, NY.

As per a concurrent interview with Staff H, the staff member confirmed this finding and said he will inform the facility Administrator.


NFPA 101-2000 Life Safety Code: 38.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3


4. Based on observation and staff interview, the facility failed to maintain the integrity of the 2-hour fire barrier separating the MSK (the MSK Building is an existing business occupancy) Building and the McGann Building at the Lower Level.

Findings:

On 05/09/16 at 1:25PM, an unsealed cable penetration was observed above the ceiling of the 2-hour fire barrier directly above the ninety (90) minute double door at the Lower Level of the McGann Building and the MSK Building.

A concurrent interview with Staff H on 05/09/16 at 1:25PM confirmed this condition. The staff member said he will inform the facility Administrator.

NFPA 101-2000 Life Safety Code 8.2.3.2.4.2
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1. Based on observation and staff interview during the survey, the facility failed to ensure that all panelboard circuits and circuit modifications were legibly identified as to purpose or use on a Circuit Directory located on the face or inside of the panel doors in accordance with the Requirements of NFPA 70, National Electrical Code.

The findings include, but are not limited to, the following:

a. On 05/11/16 at 10:20AM, the review of the Panel Directory for Panel "LS-3" on the 3rd Floor of the facility revealed that the function of Circuits 2, 4, 5, 6, 8, 10, 12 and 14 were only identified as "EXISTING". The lack of information of the specific functions of these circuits could hamper facility staff and/or emergency responders if they have to try to shut off a malfunctioning circuit or circuits.

b. On 05/11/16 at 1:24PM, the Panel Directory of Panel "LP-G-ECB -A (LS)" in the Lower Level of the facility was noted to be missing. The lack of the Directory could hamper facility staff and/or emergency responders if they have to try to shut off a malfunctioning circuit or circuits

As per concurrent interview with the Staff G, the staff member acknowledged the above mentioned deficiencies and said that he will inform facility Administration of them.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 384-13


2. Based on observations and staff interview during the survey, the facility failed to ensure that electrical wiring was installed in a neat and workman like manner or maintained in good repair and that unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment were provided in accordance with the requirements of NFPA 70, National Electrical Code.

Findings:

a. On 05/11/16 at 10:30AM, unprotected openings due to five (5) missing circuit blanks (for Circuits #3, #4, #7, #9 and #10) were noted in Electrical Panel "LP-3-ECB" and an unprotected opening due to a missing circuit blank (for Circuit #2) was noted in Electrical Panel "LP-3-ELS" on the 3rd Floor of the facility.

b. On 05/11/16 at 1:34PM, an electrical junction box located above a suspended ceiling in a Lower-Level Corridor of the facility (vicinity of the OR Booking Office and Exit Stair #6) was noted be missing a cover plate on one (1) side of the box.

As per concurrent interview with Staff G, the staff member acknowledged the above mentioned deficiencies and said that he will inform facility Administration of them.

c. On 05/10/15 at 11:20AM, an open junction box was observed on the wall of the Central Plant Room.

d. On 05/10/15 at 1:31PM, an open junction box was noted above the suspended ceiling in the vicinity of Room 276.

e. On 5/11/16 at 11:21AM, an open electrical junction box was observed above the suspended ceiling of the Film Library Room in the Radiology Unit at the Basement of the building.

f. On 05/10/16 at 10:20AM, a broken duplex electrical receptacle was observed at the balcony of the Chapel.

g. On 05/11/16 at 10:10AM, a broken duplex electrical receptacle cover plate was observed by the corridor of Pulmonary Office in the vicinity of Room 417.

h. On 05/11/16 at 10:35AM, a broken duplex electrical receptacle cover plate was noted inside the Telephone Closet at the 3rd Floor Pain Management Unit.

i. On 05/11/16 at 2:00PM, a duplex electrical receptacle labeled EPL-ORCKT32 in between the corridor wall of Operating Rooms 7 and 8 was observed to be cracked.

As per concurrent interview with Staff H, the staff member confirmed these findings and said he will inform the facility Administrator.


3. Based on observation and staff interview, the facility failed to ensure that the electrical wiring and equipment were in accordance with the requirements of NFPA 70, National Electrical Code. Specific reference is made to the requirement to remove all temporary wiring and light fixtures immediately upon completion of construction.

Findings:

a. On 05/09/16 at 2:11PM, temporary wiring and lighting fixtures were observed above the suspended ceiling of the Radiation Oncology Unit in the Lower Level of the McGann Building.

b. On 05/10/16 at 11:25AM, temporary wiring and lighting fixtures were noted inside the Central Plant Room located at the 1st Floor of the existing building.

As per concurrent interview with Staff H, the staff member confirmed these findings and said he will inform the facility Administrator.


4. Based on observation, record review and staff interview, the facility failed to ensure that electrical equipment was used in accordance with its listing and that flexible wiring was not used as a substitute for the fixed wiring of a structure.

Findings:

On 05/09/16 at 1:45PM, two (2) serially connected relocatable power taps were noted at the Receptionist Area in the Outpatient Rehabilitation Unit. Relocatable power taps must be used in accordance with their listing.

On 05/11/16 at 10:45AM, it was noted that a window Air Conditioner (AC) Unit was connected directly into an extension cord in Staff Locker Room 3152 which is in violation of the facility's Policy and Procedure titled "Plant Operations Policy and Procedure Manual" last revised on 06/30/15.

As per concurrent interview with Staff H, the staff member confirmed these findings and said he will inform the facility Administrator.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: 110-3, 400-8