HospitalInspections.org

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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that corridors were separated from all other areas by partitions complying with Sections 19.3.6.2 through 19.3.6.5. Specifically, corridor walls (smoke partitions) in sprinkler protected areas were not completely smoke tight.

Findings:

a) On 06/10/14 at 10:30AM the cable penetration of a corridor smoke partition wall (vicinity of Electrical Room H1664) was found to be only partially sealed.

b) On 06/10/14 at 1:13PM, the top-of-wall assembly of a corridor smoke partition wall (vicinity of Electrical Room D3513) was found to be only partially sealed.

As per concurrent interviews with the facility's Director of Facilities Management, he will have these openings sealed as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.1
10NYCRR, 405.24 (b), 711.2 (a) (1)
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1. Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that Dutch doors that open into exit access corridors in Existing Health Care Occupancies have upper leaf and lower leaf are equipped with a latching device and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.

Findings:

On 06/09/14 at 1:58PM a Dutch door to the Ground Floor Mail Room was found to lack an approved positive latching device (the only latching device provided was a manually operated sliding bolt). As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.6
10NYCRR, 405.24 (b), 711.2 (a) (1)

2. Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 19.3.6.3.2 requires that corridor doors in Existing Health Care Occupancies to be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction (e.g., doors shall be provided with positive latching hardware). Specific reference is made to the lack of positive latching hardware (e.g., automatic flush bolts).

Findings:

a) On 06/09/14 at 12:54PM the inactive leaf to a set of double doors to an electrical closet in the Emergency Department was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire. As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

b) On 06/10/14 at 9:51AM a power-assisted sliding door to a corridor from the Ambulatory Surgery Unit Pre-Op Room on the 1st Floor was found to lack a positive latching device.

c) On 06/10/14 at 12:38PM the inactive leaf to a set of double doors to Storage Closet D4011 on the 4th Floor was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire. As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

d) On 06/10/14 at 12:58PM the inactive leaf to a set of double doors to Electrical Closet D3559 on the 3rd Floor was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire.

e) On 06/10/14 at 1:57PM the inactive leaf to a set of double doors to Electrical Closet D1522 on the 1st Floor was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.2
10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and interview during the Federal Recertification Survey, the facility failed to ensure that existing openings in corridor walls in smoke compartments that were not provided with complete automatic sprinkler protection were limited to only twenty (20) square inches.

Findings:

On 06/09/14 an approximately 22-inch by 38-inch sliding glass vision panel was noted in a corridor facing wall of the Switchboard Room on the Ground Floor. This area of the building lacks complete automatic sprinkler protection. As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.5
10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that that doors to hazardous area enclosures were self-closing and kept in the closed position unless held-open by a release device complying with Section 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:

(a) The required manual fire alarm system and
(b) Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system and
(c) The automatic sprinkler system, if installed.

Findings:

a) On 06/09/14 at 12:54PM the self-closing device on the door to a Clean Utility Room in the Ground Floor Emergency Department (vicinity Treatment Room 7) was found to be in disrepair and was unable to close the door properly (it did not close the door properly when tested and needs to be adjusted).

b) On 06/10/14 at 8:20AM the door to Storage Room "B" in the 1st Floor Operating Room Unit was found to be tied in the open position using a cable. This is an unapproved door hold-open device. The Director of Facilities Management took immediate corrective action and removed the improper hold-open device from this door.

c) On 06/10/14 at 8:25AM the self-closing device on the door to Storage Room "A" in the 1st Floor Operating Room Unit was found to be in disrepair (it did not close the door properly when tested and needs to be adjusted).

d) On 06/10/14 at 10:40AM the door to a Dietary Storage Room Ground Floor Kitchen Area was found to be tied in the open position using a bungee cord. This is an unapproved door hold-open device. It was also noted that this door lacked a self-closing device. The Director of Facilities Management took immediate corrective action and removed the improper hold-open device from this door. He also stated that he would have a self-closing device installed as soon as possible.

e) On 06/10/14 at 10:45AM the self-closing device on the door to a combination Dietary Storage Area / Compressor Equipment Area in the Ground Floor Dietary Department was found to be in disrepair and was unable to close the door properly (it did not close the door properly when tested and needs to be adjusted).

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.19.3.2.1, 19.2.2.2.6, 8.4.1.3, 7.2.1.8
10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that existing smoke barrier walls were constructed to have at least a ½-hour fire resistance rating and that smoke dampers are provided in duct penetrations of smoke barriers in smoke compartments that are not protected throughout by an approved, supervised automatic sprinkler system in accordance NFPA 13.

Findings:

a) On 06/09/14 at 12:01PM an unsealed penetration was noted in a smoke barrier wall (above the cross-corridor doors near Room 385. As per concurrent interview with the facility's Director of Facilities Management, he will have this penetration sealed immediately.

b) On 06/10/14 at 1:40PM a duct penetration of a 2nd Floor smoke barrier (above cross-corridor near Room D2050) that contained a fire/smoke damper was found to have been sealed with a firestopping material (caulk) rather than by metal angles. Firestopping material may, when exposed to the heat of a fire, expand and could crush the duct and prevent the fire/smoke damper within the duct from operating properly. As per concurrent interview with the facility's Director of Facilities Management, he will have this duct penetration sealed with the appropriate materials as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3
10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that battery-powered emergency lighting units were maintained in working order.

Findings:

On the morning of 06/10/14, between 10:00AM and 10:05AM, four (4) out of five (5) battery-powered emergency lighting fixtures located in Electrical Service Room O failed to operate when tested. As per concurrent interviews with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.9.1, 7.9
10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that tactile exit stair signage was installed adjacent to the latch side of the door 60-inches above the finished floor to the centerline of the sign.

Findings:

On the morning of 06/10/14 between 8:59AM and 9:20AM, tactile exit signs were found to have been improperly installed directly on exit doors rather than on the wall adjacent to the latch side of the doors at Exit Stairs "E5", "E6" and "E7" on the 2nd Floor of the building. As per concurrent interviews with the facility's Director of Facilities Management, he will have these signs installed at the required location as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.10.1, 7.10.1.3
10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and staff interviews during the Federal Recertification Survey, the facility failed to ensure that automatic sprinkler protection was provided in all required areas.

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

a) On 06/09/14 at 1:02PM a storage closet in the Ground Floor Emergency Department was noted to lack a required automatic sprinkler.

b) On 06/09/14 at 1:20PM a Ground Floor Laboratory Department Office Suite was noted to lack required automatic sprinklers.

c) On 06/09/14 at 1:35PM required automatic sprinklers were noted to be missing from a small closet (where the sprinkler inspectors test valve is located) and the corridor outside of the closet in the Ground Floor Radiation Oncology Department.

d) On 06/10/14 at 11:00AM required automatic sprinklers were noted to be missing in two (2) moveable partition/room divider storage closets in the Ground Floor Cafeteria.

e) On 06/11/14 at 9:54AM a required automatic sprinkler was noted to be missing underneath the 5-foot wide "Grand Staircase" in the Ground Floor of the building (near the Auditorium/Lecture Center in the Atrium / Main Lobby of the facility).

As per concurrent interviews with the facility's Director of Facilities Management, he will have sprinklers installed is the required locations where they are missing as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.5.1, 19.1.1.4.5, 9.7.1., NFPA 13-1999 Standard for the Installation of Sprinkler Systems: 5-1.1
10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all fire sprinklers and associated components were maintained in good repair, properly installed, and/or maintained free of foreign material.

Findings:

a) On 06/09/14 at 2:43PM a recessed automatic sprinkler by the entrance to the 2nd Floor Pediatrics Unit was noted to be missing its escutcheon cover plate.

b) On 06/10/14 at 9:02AM paint (a foreign material) was noted on the operable parts of a sprinkler in Linen Chute Room E2729.

c) On the morning of 06/10/14 between 10:40 and 10:50AM in the Ground Floor Kitchen Area, at least five (5) pendant automatic sprinklers were missing their escutcheons and at least six (6) pendant automatic sprinkler deflectors were either flush with or slightly above the surface of the ceiling in this room (the deflectors of pendant sprinklers are required to be below the surface of the ceiling so that sprinkler water discharge is not obstructed).

d) On 06/10/14 at 12:30PM the deflector of an upright sprinkler in 4th Floor Closet D4505 was installed less than 1-inch from an overhead beam. A minimum separation distance of 1-inch is required.

e) On 06/11/14 at 9:43AM the deflector of an upright sprinkler in Ground Floor Electrical Service Room Q was installed less than 1-inch from an overhead beam. A minimum separation distance of 1-inch is required.

f) On 06/11/14 at 10:28AM paint (a foreign material) was noted on the operable parts of a sprinkler in the Nitrous Oxide Manifold Room in Ground Floor Mechanical Room 16. In addition, the escutcheon cover plate for this sprinkler was missing.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 2-1
10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and record (i.e., panelboard schedule) reviews, and staff interviews during the Federal Recertification Survey, the facility was not provided with a Type 1 Essential Electrical System installed in accordance with NFPA 99. For example, the facility did not ensure that Emergency System-Life Safety Branch wiring was separated from Emergency System-Critical Branch wiring. This deficiency was noted in a recently renovated / constructed area of this facility.

Findings:

On 06/10/14 at 1:20PM Emergency Power Panel "3LCHI" in D3507 Electrical Service Room U has Emergency System - Life Safety Branch loads (e.g., corridor lighting,) and Emergency System -Critical Branch loads (i.e., NICU lights, Procedure Room task lights). As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.5.1, 9.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9
10NYCRR, 405.24 (b), 711.2 (a) (1)
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1. Based on observations and staff interviews during the Federal Recertification Survey, the facility failed to ensure that the integrity of all fire resistance rated walls was maintained.

Findings:

a) On 06/09/14 at 2:45PM a partially sealed membrane penetration (a door motion sensor) was noted in one (1) side of a 2nd Floor fire barrier wall that separates the "D" Wing from the "A/B" Wings.

b) On 06/10/14 at 9:25AM two (2) partially sealed cable penetrations were noted in one (1) side of a 1st Floor fire barrier wall that separates the "D" Wing from the "A/B" Wings.

c) On 06/10/14 at 9:32AM a partially sealed conduit was noted in one (1) side of a 1st Floor fire barrier wall that separates the "C" Wing from the "A/B" Wings.

As per concurrent interviews with the facility's Director of Facilities Management, he will have these penetrations sealed immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 8.2.3
10NYCRR, 405.24 (b), 711.2 (a) (1)

2. Based on observations and staff interviews during the Federal Recertification Survey, the facility failed to ensure that containers of combustible liquids were properly stored.

Findings:

On 06/10/14 at 10:43AM two (2) seven (7) ounce containers of Sterno Cooking Fuel were found to be stored in a Dietary Department Storage Room near combustible materials (the one near the load dock) rather than in the approved fire resistant combustible liquid storage cabinet located nearby. As per concurrent interviews with the facility's Director of Facilities Management and Director of Dietary Services, these containers should have been stored in the fire resistance rated cabinet rather than out on a shelf. Immediate corrective action was taken by relocating these cans of liquid fuel to the approved combustible liquids storage cabinet.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 8.4.3.1, NFPA 30, Flammable and Combustible Liquids Code
10NYCRR, 405.24 (b), 711.2 (a) (1)

3. Based on observations and staff interviews during the Federal Recertification Survey, the facility failed to ensure that existing assembly occupancies that have a capacity to hold more than fifty (50) occupants were provided with at least two (2) means of egress.

Findings:

On 06/11/14 at 11:17AM it was noted that Ground Floor Conference Room 2 was approximately 1050 Square Feet in size and could have an occupant load of up to seventy-two (72) occupants (based on 15-square feet per occupant for an assembly occupancy that has a less concentrated use and no fixed seating). For a room with this occupant load (e.g., more than fifty {50} occupants) at least two (2) means of egress would be required. At the time of the inspection only thirty-eight (38) seats were provided in this room. As per concurrent interview with the facility's Director of Facilities Management, this room is never used by more than forty (40) people and that he will post signage limiting occupancy of this room to no more than forty-nine (49) occupants.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 13.1.7, 13.2, 7.3.1, 7.4
10NYCRR, 405.24 (b), 711.2 (a) (1)

4. Based on staff interview during the Federal Recertification Survey, the facility failed to ensure that in Atriums where an engineered smoke control system is installed meet the requirements of 8.2.5.6(5), that the system is independently activated by both the required automatic sprinkler system and by manual controls that are readily accessible to the Fire Department.

Findings:

The building has a three (3) story Atrium that is provided with beam smoke detection, automatic sprinklers, and a smoke control system.

As per interview with the facility's Director of Facilities Management on 06/11/14 at 1:40PM, the building's Atrium smoke control system is not independently activated by the automatic sprinkler system and is provided with manual controls for use by the Fire Department only. He said that the installation of only manual controls was as per the requirement of the Nassau County (NY) Fire Marshal.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 8.2.5.6 (6)
10NYCRR, 405.24 (b), 711.2 (a) (1)

5. Based on observations and interviews during the Federal Recertification Survey, the following deficiencies apply to the Multi-Specialty Care Center Outpatient Building located at 440 Merrick Road, Oceanside. New York. This building was classified as an Existing Business Occupancy (i.e., NFPA 101-2000: Chapter 39) because the project to construct this facility was approved by the New York State Department of Health prior to 03/13/2003 adoption of the 2000 Edition of NFPA 101 by the Federal Centers for Medicare/Medicaid Services.

Findings:

a) The facility failed to ensure that Plexiglas guards on open stairways were maintained in good repair. For example, on the morning of 06/11/14 Plexiglas guards at the 2nd Floor landings (vicinity of the Waiting Area) of the two (2) open staircases that both serve the two (2) story "Mini-Atrium" in the building were noted to be cracked/in disrepair.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.2.2.4.1, 7.1.8, 4.6.12.1
10NYCRR, 405.24 (b), 711.2 (a) (1)

b) The facility failed to ensure that battery-powered exit directional signs were maintained in a functional condition. For example, on the morning of 06/11/14, two (2) different battery-powered exits signs, specifically exit directional signs "EX2-8" on the 2nd Floor and "EX1-12" on the 1st Floor failed to operate when tested.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.10.4, 4.6.12.1
10NYCRR, 405.24 (b), 711.2 (a) (1)

c) The facility failed to ensure that electrically powered biomedical equipment was used in accordance with its Manufacturer's instructions. Reference is made to an electrically powered exam table that was required to be connected to a listed Hospital Grade receptacle that was improperly connected to a non-Hospital Grade portable multi-receptacle temporary power tap in 2nd Floor Exam Room 2 on 06/11/14 at 8:27AM. In addition, on the morning of 06/11/14 1st Floor Exam Room1 an electrically powered exam table that was required to be connected to a listed Hospital Grade receptacle that was improperly connected to a non-Hospital Grade duplex receptacle. It was also noted on the morning if 06/11/14 that a duplex receptacle in 1st Floor Exam Room 1 and a duplex receptacle in Exam Room 3 were cracked and needed to be replaced, that 1st Floor Exam Room 5 lacked required Hospital Grade receptacles, and that an extension cord was being improperly used in the 1st Floor Reception Area.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-3 (b)
10NYCRR, 405.24 (b), 711.2 (a) (1)

d) The facility failed to ensure that receptacles that may be subject to wetting are provide with ground fault circuit interrupter protection. For example, on 06/11/14 at 8:30AM the electrical cord set for a hydroculator in a 2nd Floor Outpatient Occupational Therapy Treatment Area was found to be connected to a standard Hospital Grade receptacle rather than a Hospital Grade ground fault circuit interrupter.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 517-20 (a)
10NYCRR, 405.24 (b), 711.2 (a) (1)

e) The facility failed to ensure that sprinkler systems were maintained in good repair. Reference is made to a missing sprinkler escutcheon cover plate in the unisex accessible toilet room on the 2nd Floor (vicinity of the Staff Room and the Outpatient Occupational Therapy Treatment Room).

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 2-1
10NYCRR, 405.24 (b), 711.2 (a) (1)

f) The facility failed to ensure that designated means of egress did not involve passing through any intervening rooms other than corridors, lobbies, or other spaces permitted to be open to the corridor. Reference is made to the following, on 06/11/14 at 8:36AM it was noted that exiting from the 1st Floor Patient Waiting Area was improperly directed through a hazardous area (a former Medical Doctor Dictation Work Station that had been converted into a Combustible Storage Area).

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.2.5.1, 7.5.1.2, 7.1.10
10NYCRR, 405.24 (b), 711.2 (a) (1)

g) The facility failed to ensure that at least two (2) spare sprinkler heads was maintained on the premises. For example, on 06/11/14 at 8:48AM it was noted that the facility has sidewall sprinklers installed in the building but that there were no spare sidewall sprinklers in the spare sprinkler storage cabinet at the time of the inspection.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 13-1999, Standard for the Installation of Sprinkler Systems: 3-2.9
10NYCRR, 405.24 (b), 711.2 (a) (1)

As per concurrent interviews with the facility's Director of Facilities Management, he will notify facility Administration concerning the above-mentioned conditions.

6. Based on observations and interviews during the Federal Recertification Survey, the following deficiencies apply to the Family Health Center Outpatient Building located at 196 Merrick Road, Oceanside, New York. This building was classified as an Existing Business Occupancy (i.e., NFPA 101-2000: Chapter 39) because the project to construct this facility was approved by the New York State Department of Health prior to 03/13/2003 adoption of the 2000 Edition of NFPA 101 by the Federal Centers for Medicare / Medicaid Services.

Findings:

a) The facility failed to ensure that at least two (2) spare sprinkler heads was maintained on the premises. For example, on 06/11/14 at 9:10AM it was noted that the facility has sidewall sprinklers installed in the building but that there were no spare sidewall sprinklers in the spare sprinkler storage cabinet at the time of the inspection. As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning the above-mentioned condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 13-1999, Standard for the Installation of Sprinkler Systems: 3-2.9
10NYCRR, 405.24 (b), 711.2 (a) (1)

b) The facility failed to ensure that sprinkler protected hazardous (combustible material) areas were enclosed with smoke partitions that had self-closing doors to help prevent the transfer of smoke to occupied areas in the event of a fire. Reference is made to the following example, on 06/11/14 at 9:15AM one (1) of the two (2) doors to the Medical Records Storage Area was noted to be a sliding pocket door that lacked a self-closing device and that was not positive latching. As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning the above-mentioned condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.3.2.1, 8.4.1
10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and record (i.e., panelboard schedule) reviews, and staff interviews during the Federal Recertification Survey, the facility was not provided with a Type 1 Essential Electrical System that was divided into separate critical branch, life safety ranch, and equipment systems in accordance with NFPA 99. In addition, the facility failed to ensure that normal service wiring was separated from emergency service wiring. These deficiencies were noted in existing areas of this hospital.

Findings:

a) On 06/09/14 at 11:55AM review of the Emergency Power Panel Directory for Panel "4F-2E" on the 4th Floor revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., corridor lights), Emergency System-Critical Branch loads (e.g., room lights, corridor receptacles) and Equipment System loads (e.g., fan coil units).

b) On 06/09/14 at 12:07PM review of the Emergency Power Panel Directory for Panel "3F-2E" on the 3rd Floor revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., corridor lights), Emergency System-Critical Branch loads (e.g., Nurse call system, corridor receptacles) and Equipment System loads (e.g., fan coil units).

c) On 06/09/14 at 2:10PM review of the Emergency Power Panel Directory for Panel "GH-53E" on the Ground Floor revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., fire alarm control panel, exit lights) and Emergency System-Critical Branch loads (e.g., Nurse call system, room receptacles, task lighting, x-ray viewers).

d) On 06/09/14 at 2:15PM review of the Emergency Power Panel Directory for Panel "HGL-CL1" on the Ground Floor revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., emergency lights) and Emergency System-Critical Branch loads (e.g., Nurse call system, room receptacles, task lighting).

e) On 06/09/14 at 2:25PM observations of interior of wiring raceways in a 2nd Floor Electrical Closet (vicinity of the Visitor's Lounge) revealed that wiring from normal service electrical panel "2G34" and wiring from Emergency Service Electrical Panel 2G3E were not separated from each other. Emergency power and normal power wiring are required to be kept separated from each other. In addition, review of the Emergency Power Panel Directory for Panel "2G-38E" in the above-mentioned electrical closet reveled that it served both Emergency System-Life Safety Branch loads (e.g., exit signs) and Emergency System-Critical Branch loads (e.g., crash cart receptacle, room receptacles).

f) On 06/10/14 at 8:45AM, review of the Emergency Power Panel Directory for Panel "1G35-E" on the 1st Floor Operating Room Unit revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., corridor lights, exit signs, medical gas alarms) and Emergency System-Critical Branch loads (e.g., Nurse call system, room receptacles, refrigerator receptacle).

g) On 06/10/14 at 11:10AM, review of the Emergency Power Panel Directory for Panel "GG47E" in Ground Floor Electrical Service Room Y revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., corridor lights, exit signs, stairway lights), Emergency System-Critical Branch loads (e.g., room receptacles), and Equipment System loads (dietary chiller control, air conditioner). In addition, review of the Emergency Power Panel Directory for Panel "GG48E" that was also located in Ground Floor Electrical Service Room Y reveled that it served both Emergency System-Life Safety Branch loads (e.g., emergency lights) and Emergency System-Critical Branch loads (e.g., Pharmacy receptacles).

As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning the above-mentioned conditions.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 4.6.1.2, 19.5.1, 9.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551, NFPA 70-1965, National Electrical Code: Article 700-9, NFPA 70-1968, National Electrical Code: Article 700-9, NFPA 70-1971, National Electrical Code: Article 700-9
10NYCRR, 405.24 (b), 711.2 (a) (1), 711.2 (a) (20)
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1. Based on observations and staff interview during the Federal Recertification 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 the morning of 06/09/16 three (3) unprotected openings caused by missing circuit breakers were noted in Electrical Panel "4F-3", one (1) unprotected opening caused by missing circuit breaker was noted in Electrical Panel "4F1", one (1) unprotected opening caused by missing circuit breaker was noted in Electrical Panel "4F-2E", two (2) unprotected openings caused by missing circuit breakers were noted in Electrical Panel "3F-3", and three (3) unprotected openings caused by missing circuit breakers were noted in Electrical Panel "3F-2E".

b) On the afternoon of 06/09/14 two (2) unprotected openings caused by missing circuit breakers were noted in Electrical Panel "2G-35E" and one (1) unprotected opening caused by missing circuit breaker was noted in Electrical Panel "2G-38E".

c) On 06/10/14 at 9:31AM an electrical junction box that lacked a cover plate on one (1) side of the box was noted above a suspended ceiling in a 1st Floor corridor by the accessory staircase and elevator that serve the A/B Wings.

d) On 06/10/14 at 10:51AM, an electrical extension cord was noted to be hanging down from a ceiling in the Ground Floor Dietary Department Dish Washing Area.

e) On 06/10/13 at 11:15AM an electrical extension cord was noted to be used to supply power to a water cooler in the Ground Floor Central Storage Room.

f) On the morning of 06/10/14 an electrical cord set that served the Poland Spring water refrigerated display case in the Ground Floor Cafeteria was noted to be in disrepair (was frayed near the plug-end of the cord set and needs to be replaced).

g) On 06/10/14 at 1:10PM two (2) electrical junction boxes that lacked cover plates on at least one (1) side of the box were noted above a suspended ceiling in 3rd Floor Room D3026.

h) On the morning of 06/11/14 four (4) duplex electrical receptacles in a corridor in the "On Call" resident building were noted to be cracked/in disrepair and need to be replaced.

As per concurrent interviews with the facility's Director of Facilities Management, he will notify facility Administration concerning these conditions.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-12
10NYCRR, 405.24 (b), 711.2 (a) (1)

2. Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all panelboard circuits and circuit modifications shall be 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.

Findings:

a) On 06/09/14 at 2:47PM the Circuit Directory that was located inside 2nd Floor Emergency Power Electrical Panel "A2LCL1" indicated that Circuits #15, #17, #18, #19, #21, #23, #25, #28 and #29 served "Existing Loads" but failed to identify the specific purpose that these circuits serve. As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

b) On 06/10/14 at 9:34AM the Circuit Directory that was located inside 1st Floor Emergency Power Electrical Panel "A1LCL1" indicated that Circuit #6, served an "Existing Load" but failed to identify the specific purpose that this circuit served.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 384-13
10NYCRR, 405.24 (b), 711.2 (a) (1)

3. Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all emergency system electrical receptacles in Critical Care Areas were provided with identification that indicates the panelboard and circuit number supplying them.

Findings:

On the morning of 06/10/14 one (1) duplex and two (2) quadruple electrical receptacles in the 1st Floor PACU Suite and one (1) duplex receptacle in the 1st Floor OR Suite Pump Storage Room were noted to lack identification that would indicate the panelboard and circuit number supplying them. As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 517-19 (a)
10NYCRR, 405.24 (b), 711.2 (a) (1)

4. Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that receptacles that may be subject to wetting are provided with ground fault circuit interrupter protection.

Findings:

On 06/10/14 at 9:20AM the electrical cord set for a hydroculator in a 2nd Floor Inpatient Physical Therapy Treatment Area was found to be connected to a standard Hospital Grade receptacle rather than a Hospital Grade ground fault circuit interrupter. As per concurrent interview with the facility's Director of Facilities Management, he will have a Hospital Grade ground fault circuit interrupter installed as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 517-20 (a)
10NYCRR, 405.24 (b), 711.2 (a) (1)

5. Based on observations, record review, and staff interview during the Federal Recertification Survey, the facility failed to ensure that ground fault circuit interrupter receptacles were tested at least once a month in accordance with Manufacturer's instructions.

Findings:

During the survey from 06/09/14 to 06/11/14, ground fault circuit interrupter receptacles located throughout the hospital building were noted to have been labeled by their Manufacturer "TEST MONTHLY". As per interview with the facility's Director of Facilities Management on 06/11/14 at 1:55PM, the facility had not been conducting required monthly testing of these receptacles but will start doing so as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-3 (b)
10NYCRR, 405.24 (b), 711.2 (a) (1)
.

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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that smoke detectors were installed in each Elevator Machine Room and Elevator Lobby at each floor in accordance with the Fire Fighters' Service Requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators.

Findings:

a) On 06/09/14 at 11:40AM the F-Wing Elevator Machine Room was found to lack a required smoke detector.

b) On 06/10/14 at 8:55AM the E-Wing 3rd Floor Elevator Lobby was found to lack a required smoke detector. As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.3, 9.4.3.2, ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators: 3.11.3, 211.3b
10NYCRR, 405.24 (b), 711.2 (a) (1)

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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that corridors were separated from all other areas by partitions complying with Sections 19.3.6.2 through 19.3.6.5. Specifically, corridor walls (smoke partitions) in sprinkler protected areas were not completely smoke tight.

Findings:

a) On 06/10/14 at 10:30AM the cable penetration of a corridor smoke partition wall (vicinity of Electrical Room H1664) was found to be only partially sealed.

b) On 06/10/14 at 1:13PM, the top-of-wall assembly of a corridor smoke partition wall (vicinity of Electrical Room D3513) was found to be only partially sealed.

As per concurrent interviews with the facility's Director of Facilities Management, he will have these openings sealed as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.1
10NYCRR, 405.24 (b), 711.2 (a) (1)
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1. Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that Dutch doors that open into exit access corridors in Existing Health Care Occupancies have upper leaf and lower leaf are equipped with a latching device and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.

Findings:

On 06/09/14 at 1:58PM a Dutch door to the Ground Floor Mail Room was found to lack an approved positive latching device (the only latching device provided was a manually operated sliding bolt). As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.6
10NYCRR, 405.24 (b), 711.2 (a) (1)

2. Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 19.3.6.3.2 requires that corridor doors in Existing Health Care Occupancies to be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction (e.g., doors shall be provided with positive latching hardware). Specific reference is made to the lack of positive latching hardware (e.g., automatic flush bolts).

Findings:

a) On 06/09/14 at 12:54PM the inactive leaf to a set of double doors to an electrical closet in the Emergency Department was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire. As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

b) On 06/10/14 at 9:51AM a power-assisted sliding door to a corridor from the Ambulatory Surgery Unit Pre-Op Room on the 1st Floor was found to lack a positive latching device.

c) On 06/10/14 at 12:38PM the inactive leaf to a set of double doors to Storage Closet D4011 on the 4th Floor was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire. As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

d) On 06/10/14 at 12:58PM the inactive leaf to a set of double doors to Electrical Closet D3559 on the 3rd Floor was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire.

e) On 06/10/14 at 1:57PM the inactive leaf to a set of double doors to Electrical Closet D1522 on the 1st Floor was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.2
10NYCRR, 405.24 (b), 711.2 (a) (1)
.

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Based on observations and interview during the Federal Recertification Survey, the facility failed to ensure that existing openings in corridor walls in smoke compartments that were not provided with complete automatic sprinkler protection were limited to only twenty (20) square inches.

Findings:

On 06/09/14 an approximately 22-inch by 38-inch sliding glass vision panel was noted in a corridor facing wall of the Switchboard Room on the Ground Floor. This area of the building lacks complete automatic sprinkler protection. As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.5
10NYCRR, 405.24 (b), 711.2 (a) (1)
.

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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that that doors to hazardous area enclosures were self-closing and kept in the closed position unless held-open by a release device complying with Section 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:

(a) The required manual fire alarm system and
(b) Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system and
(c) The automatic sprinkler system, if installed.

Findings:

a) On 06/09/14 at 12:54PM the self-closing device on the door to a Clean Utility Room in the Ground Floor Emergency Department (vicinity Treatment Room 7) was found to be in disrepair and was unable to close the door properly (it did not close the door properly when tested and needs to be adjusted).

b) On 06/10/14 at 8:20AM the door to Storage Room "B" in the 1st Floor Operating Room Unit was found to be tied in the open position using a cable. This is an unapproved door hold-open device. The Director of Facilities Management took immediate corrective action and removed the improper hold-open device from this door.

c) On 06/10/14 at 8:25AM the self-closing device on the door to Storage Room "A" in the 1st Floor Operating Room Unit was found to be in disrepair (it did not close the door properly when tested and needs to be adjusted).

d) On 06/10/14 at 10:40AM the door to a Dietary Storage Room Ground Floor Kitchen Area was found to be tied in the open position using a bungee cord. This is an unapproved door hold-open device. It was also noted that this door lacked a self-closing device. The Director of Facilities Management took immediate corrective action and removed the improper hold-open device from this door. He also stated that he would have a self-closing device installed as soon as possible.

e) On 06/10/14 at 10:45AM the self-closing device on the door to a combination Dietary Storage Area / Compressor Equipment Area in the Ground Floor Dietary Department was found to be in disrepair and was unable to close the door properly (it did not close the door properly when tested and needs to be adjusted).

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.19.3.2.1, 19.2.2.2.6, 8.4.1.3, 7.2.1.8
10NYCRR, 405.24 (b), 711.2 (a) (1)
.

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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that existing smoke barrier walls were constructed to have at least a ½-hour fire resistance rating and that smoke dampers are provided in duct penetrations of smoke barriers in smoke compartments that are not protected throughout by an approved, supervised automatic sprinkler system in accordance NFPA 13.

Findings:

a) On 06/09/14 at 12:01PM an unsealed penetration was noted in a smoke barrier wall (above the cross-corridor doors near Room 385. As per concurrent interview with the facility's Director of Facilities Management, he will have this penetration sealed immediately.

b) On 06/10/14 at 1:40PM a duct penetration of a 2nd Floor smoke barrier (above cross-corridor near Room D2050) that contained a fire/smoke damper was found to have been sealed with a firestopping material (caulk) rather than by metal angles. Firestopping material may, when exposed to the heat of a fire, expand and could crush the duct and prevent the fire/smoke damper within the duct from operating properly. As per concurrent interview with the facility's Director of Facilities Management, he will have this duct penetration sealed with the appropriate materials as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3
10NYCRR, 405.24 (b), 711.2 (a) (1)
.

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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that battery-powered emergency lighting units were maintained in working order.

Findings:

On the morning of 06/10/14, between 10:00AM and 10:05AM, four (4) out of five (5) battery-powered emergency lighting fixtures located in Electrical Service Room O failed to operate when tested. As per concurrent interviews with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.9.1, 7.9
10NYCRR, 405.24 (b), 711.2 (a) (1)
.

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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that tactile exit stair signage was installed adjacent to the latch side of the door 60-inches above the finished floor to the centerline of the sign.

Findings:

On the morning of 06/10/14 between 8:59AM and 9:20AM, tactile exit signs were found to have been improperly installed directly on exit doors rather than on the wall adjacent to the latch side of the doors at Exit Stairs "E5", "E6" and "E7" on the 2nd Floor of the building. As per concurrent interviews with the facility's Director of Facilities Management, he will have these signs installed at the required location as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.2.10.1, 7.10.1.3
10NYCRR, 405.24 (b), 711.2 (a) (1)
.

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Based on observations and staff interviews during the Federal Recertification Survey, the facility failed to ensure that automatic sprinkler protection was provided in all required areas.

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

a) On 06/09/14 at 1:02PM a storage closet in the Ground Floor Emergency Department was noted to lack a required automatic sprinkler.

b) On 06/09/14 at 1:20PM a Ground Floor Laboratory Department Office Suite was noted to lack required automatic sprinklers.

c) On 06/09/14 at 1:35PM required automatic sprinklers were noted to be missing from a small closet (where the sprinkler inspectors test valve is located) and the corridor outside of the closet in the Ground Floor Radiation Oncology Department.

d) On 06/10/14 at 11:00AM required automatic sprinklers were noted to be missing in two (2) moveable partition/room divider storage closets in the Ground Floor Cafeteria.

e) On 06/11/14 at 9:54AM a required automatic sprinkler was noted to be missing underneath the 5-foot wide "Grand Staircase" in the Ground Floor of the building (near the Auditorium/Lecture Center in the Atrium / Main Lobby of the facility).

As per concurrent interviews with the facility's Director of Facilities Management, he will have sprinklers installed is the required locations where they are missing as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.5.1, 19.1.1.4.5, 9.7.1., NFPA 13-1999 Standard for the Installation of Sprinkler Systems: 5-1.1
10NYCRR, 405.24 (b), 711.2 (a) (1)
.

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Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all fire sprinklers and associated components were maintained in good repair, properly installed, and/or maintained free of foreign material.

Findings:

a) On 06/09/14 at 2:43PM a recessed automatic sprinkler by the entrance to the 2nd Floor Pediatrics Unit was noted to be missing its escutcheon cover plate.

b) On 06/10/14 at 9:02AM paint (a foreign material) was noted on the operable parts of a sprinkler in Linen Chute Room E2729.

c) On the morning of 06/10/14 between 10:40 and 10:50AM in the Ground Floor Kitchen Area, at least five (5) pendant automatic sprinklers were missing their escutcheons and at least six (6) pendant automatic sprinkler deflectors were either flush with or slightly above the surface of the ceiling in this room (the deflectors of pendant sprinklers are required to be below the surface of the ceiling so that sprinkler water discharge is not obstructed).

d) On 06/10/14 at 12:30PM the deflector of an upright sprinkler in 4th Floor Closet D4505 was installed less than 1-inch from an overhead beam. A minimum separation distance of 1-inch is required.

e) On 06/11/14 at 9:43AM the deflector of an upright sprinkler in Ground Floor Electrical Service Room Q was installed less than 1-inch from an overhead beam. A minimum separation distance of 1-inch is required.

f) On 06/11/14 at 10:28AM paint (a foreign material) was noted on the operable parts of a sprinkler in the Nitrous Oxide Manifold Room in Ground Floor Mechanical Room 16. In addition, the escutcheon cover plate for this sprinkler was missing.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 2-1
10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and record (i.e., panelboard schedule) reviews, and staff interviews during the Federal Recertification Survey, the facility was not provided with a Type 1 Essential Electrical System installed in accordance with NFPA 99. For example, the facility did not ensure that Emergency System-Life Safety Branch wiring was separated from Emergency System-Critical Branch wiring. This deficiency was noted in a recently renovated / constructed area of this facility.

Findings:

On 06/10/14 at 1:20PM Emergency Power Panel "3LCHI" in D3507 Electrical Service Room U has Emergency System - Life Safety Branch loads (e.g., corridor lighting,) and Emergency System -Critical Branch loads (i.e., NICU lights, Procedure Room task lights). As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.5.1, 9.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9
10NYCRR, 405.24 (b), 711.2 (a) (1)
.

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1. Based on observations and staff interviews during the Federal Recertification Survey, the facility failed to ensure that the integrity of all fire resistance rated walls was maintained.

Findings:

a) On 06/09/14 at 2:45PM a partially sealed membrane penetration (a door motion sensor) was noted in one (1) side of a 2nd Floor fire barrier wall that separates the "D" Wing from the "A/B" Wings.

b) On 06/10/14 at 9:25AM two (2) partially sealed cable penetrations were noted in one (1) side of a 1st Floor fire barrier wall that separates the "D" Wing from the "A/B" Wings.

c) On 06/10/14 at 9:32AM a partially sealed conduit was noted in one (1) side of a 1st Floor fire barrier wall that separates the "C" Wing from the "A/B" Wings.

As per concurrent interviews with the facility's Director of Facilities Management, he will have these penetrations sealed immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 8.2.3
10NYCRR, 405.24 (b), 711.2 (a) (1)

2. Based on observations and staff interviews during the Federal Recertification Survey, the facility failed to ensure that containers of combustible liquids were properly stored.

Findings:

On 06/10/14 at 10:43AM two (2) seven (7) ounce containers of Sterno Cooking Fuel were found to be stored in a Dietary Department Storage Room near combustible materials (the one near the load dock) rather than in the approved fire resistant combustible liquid storage cabinet located nearby. As per concurrent interviews with the facility's Director of Facilities Management and Director of Dietary Services, these containers should have been stored in the fire resistance rated cabinet rather than out on a shelf. Immediate corrective action was taken by relocating these cans of liquid fuel to the approved combustible liquids storage cabinet.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 8.4.3.1, NFPA 30, Flammable and Combustible Liquids Code
10NYCRR, 405.24 (b), 711.2 (a) (1)

3. Based on observations and staff interviews during the Federal Recertification Survey, the facility failed to ensure that existing assembly occupancies that have a capacity to hold more than fifty (50) occupants were provided with at least two (2) means of egress.

Findings:

On 06/11/14 at 11:17AM it was noted that Ground Floor Conference Room 2 was approximately 1050 Square Feet in size and could have an occupant load of up to seventy-two (72) occupants (based on 15-square feet per occupant for an assembly occupancy that has a less concentrated use and no fixed seating). For a room with this occupant load (e.g., more than fifty {50} occupants) at least two (2) means of egress would be required. At the time of the inspection only thirty-eight (38) seats were provided in this room. As per concurrent interview with the facility's Director of Facilities Management, this room is never used by more than forty (40) people and that he will post signage limiting occupancy of this room to no more than forty-nine (49) occupants.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 13.1.7, 13.2, 7.3.1, 7.4
10NYCRR, 405.24 (b), 711.2 (a) (1)

4. Based on staff interview during the Federal Recertification Survey, the facility failed to ensure that in Atriums where an engineered smoke control system is installed meet the requirements of 8.2.5.6(5), that the system is independently activated by both the required automatic sprinkler system and by manual controls that are readily accessible to the Fire Department.

Findings:

The building has a three (3) story Atrium that is provided with beam smoke detection, automatic sprinklers, and a smoke control system.

As per interview with the facility's Director of Facilities Management on 06/11/14 at 1:40PM, the building's Atrium smoke control system is not independently activated by the automatic sprinkler system and is provided with manual controls for use by the Fire Department only. He said that the installation of only manual controls was as per the requirement of the Nassau County (NY) Fire Marshal.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 8.2.5.6 (6)
10NYCRR, 405.24 (b), 711.2 (a) (1)

5. Based on observations and interviews during the Federal Recertification Survey, the following deficiencies apply to the Multi-Specialty Care Center Outpatient Building located at 440 Merrick Road, Oceanside. New York. This building was classified as an Existing Business Occupancy (i.e., NFPA 101-2000: Chapter 39) because the project to construct this facility was approved by the New York State Department of Health prior to 03/13/2003 adoption of the 2000 Edition of NFPA 101 by the Federal Centers for Medicare/Medicaid Services.

Findings:

a) The facility failed to ensure that Plexiglas guards on open stairways were maintained in good repair. For example, on the morning of 06/11/14 Plexiglas guards at the 2nd Floor landings (vicinity of the Waiting Area) of the two (2) open staircases that both serve the two (2) story "Mini-Atrium" in the building were noted to be cracked/in disrepair.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.2.2.4.1, 7.1.8, 4.6.12.1
10NYCRR, 405.24 (b), 711.2 (a) (1)

b) The facility failed to ensure that battery-powered exit directional signs were maintained in a functional condition. For example, on the morning of 06/11/14, two (2) different battery-powered exits signs, specifically exit directional signs "EX2-8" on the 2nd Floor and "EX1-12" on the 1st Floor failed to operate when tested.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.10.4, 4.6.12.1
10NYCRR, 405.24 (b), 711.2 (a) (1)

c) The facility failed to ensure that electrically powered biomedical equipment was used in accordance with its Manufacturer's instructions. Reference is made to an electrically powered exam table that was required to be connected to a listed Hospital Grade receptacle that was improperly connected to a non-Hospital Grade portable multi-receptacle temporary power tap in 2nd Floor Exam Room 2 on 06/11/14 at 8:27AM. In addition, on the morning of 06/11/14 1st Floor Exam Room1 an electrically powered exam table that was required to be connected to a listed Hospital Grade receptacle that was improperly connected to a non-Hospital Grade duplex receptacle. It was also noted on the morning if 06/11/14 that a duplex receptacle in 1st Floor Exam Room 1 and a duplex receptacle in Exam Room 3 were cracked and needed to be replaced, that 1st Floor Exam Room 5 lacked required Hospital Grade receptacles, and that an extension cord was being improperly used in the 1st Floor Reception Area.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-3 (b)
10NYCRR, 405.24 (b), 711.2 (a) (1)

d) The facility failed to ensure that receptacles that may be subject to wetting are provide with ground fault circuit interrupter protection. For example, on 06/11/14 at 8:30AM the electrical cord set for a hydroculator in a 2nd Floor Outpatient Occupational Therapy Treatment Area was found to be connected to a standard Hospital Grade receptacle rather than a Hospital Grade ground fault circuit interrupter.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 517-20 (a)
10NYCRR, 405.24 (b), 711.2 (a) (1)

e) The facility failed to ensure that sprinkler systems were maintained in good repair. Reference is made to a missing sprinkler escutcheon cover plate in the unisex accessible toilet room on the 2nd Floor (vicinity of the Staff Room and the Outpatient Occupational Therapy Treatment Room).

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 2-1
10NYCRR, 405.24 (b), 711.2 (a) (1)

f) The facility failed to ensure that designated means of egress did not involve passing through any intervening rooms other than corridors, lobbies, or other spaces permitted to be open to the corridor. Reference is made to the following, on 06/11/14 at 8:36AM it was noted that exiting from the 1st Floor Patient Waiting Area was improperly directed through a hazardous area (a former Medical Doctor Dictation Work Station that had been converted into a Combustible Storage Area).

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.2.5.1, 7.5.1.2, 7.1.10
10NYCRR, 405.24 (b), 711.2 (a) (1)

g) The facility failed to ensure that at least two (2) spare sprinkler heads was maintained on the premises. For example, on 06/11/14 at 8:48AM it was noted that the facility has sidewall sprinklers installed in the building but that there were no spare sidewall sprinklers in the spare sprinkler storage cabinet at the time of the inspection.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 13-1999, Standard for the Installation of Sprinkler Systems: 3-2.9
10NYCRR, 405.24 (b), 711.2 (a) (1)

As per concurrent interviews with the facility's Director of Facilities Management, he will notify facility Administration concerning the above-mentioned conditions.

6. Based on observations and interviews during the Federal Recertification Survey, the following deficiencies apply to the Family Health Center Outpatient Building located at 196 Merrick Road, Oceanside, New York. This building was classified as an Existing Business Occupancy (i.e., NFPA 101-2000: Chapter 39) because the project to construct this facility was approved by the New York State Department of Health prior to 03/13/2003 adoption of the 2000 Edition of NFPA 101 by the Federal Centers for Medicare / Medicaid Services.

Findings:

a) The facility failed to ensure that at least two (2) spare sprinkler heads was maintained on the premises. For example, on 06/11/14 at 9:10AM it was noted that the facility has sidewall sprinklers installed in the building but that there were no spare sidewall sprinklers in the spare sprinkler storage cabinet at the time of the inspection. As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning the above-mentioned condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 13-1999, Standard for the Installation of Sprinkler Systems: 3-2.9
10NYCRR, 405.24 (b), 711.2 (a) (1)

b) The facility failed to ensure that sprinkler protected hazardous (combustible material) areas were enclosed with smoke partitions that had self-closing doors to help prevent the transfer of smoke to occupied areas in the event of a fire. Reference is made to the following example, on 06/11/14 at 9:15AM one (1) of the two (2) doors to the Medical Records Storage Area was noted to be a sliding pocket door that lacked a self-closing device and that was not positive latching. As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning the above-mentioned condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 39.3.2.1, 8.4.1
10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and record (i.e., panelboard schedule) reviews, and staff interviews during the Federal Recertification Survey, the facility was not provided with a Type 1 Essential Electrical System that was divided into separate critical branch, life safety ranch, and equipment systems in accordance with NFPA 99. In addition, the facility failed to ensure that normal service wiring was separated from emergency service wiring. These deficiencies were noted in existing areas of this hospital.

Findings:

a) On 06/09/14 at 11:55AM review of the Emergency Power Panel Directory for Panel "4F-2E" on the 4th Floor revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., corridor lights), Emergency System-Critical Branch loads (e.g., room lights, corridor receptacles) and Equipment System loads (e.g., fan coil units).

b) On 06/09/14 at 12:07PM review of the Emergency Power Panel Directory for Panel "3F-2E" on the 3rd Floor revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., corridor lights), Emergency System-Critical Branch loads (e.g., Nurse call system, corridor receptacles) and Equipment System loads (e.g., fan coil units).

c) On 06/09/14 at 2:10PM review of the Emergency Power Panel Directory for Panel "GH-53E" on the Ground Floor revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., fire alarm control panel, exit lights) and Emergency System-Critical Branch loads (e.g., Nurse call system, room receptacles, task lighting, x-ray viewers).

d) On 06/09/14 at 2:15PM review of the Emergency Power Panel Directory for Panel "HGL-CL1" on the Ground Floor revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., emergency lights) and Emergency System-Critical Branch loads (e.g., Nurse call system, room receptacles, task lighting).

e) On 06/09/14 at 2:25PM observations of interior of wiring raceways in a 2nd Floor Electrical Closet (vicinity of the Visitor's Lounge) revealed that wiring from normal service electrical panel "2G34" and wiring from Emergency Service Electrical Panel 2G3E were not separated from each other. Emergency power and normal power wiring are required to be kept separated from each other. In addition, review of the Emergency Power Panel Directory for Panel "2G-38E" in the above-mentioned electrical closet reveled that it served both Emergency System-Life Safety Branch loads (e.g., exit signs) and Emergency System-Critical Branch loads (e.g., crash cart receptacle, room receptacles).

f) On 06/10/14 at 8:45AM, review of the Emergency Power Panel Directory for Panel "1G35-E" on the 1st Floor Operating Room Unit revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., corridor lights, exit signs, medical gas alarms) and Emergency System-Critical Branch loads (e.g., Nurse call system, room receptacles, refrigerator receptacle).

g) On 06/10/14 at 11:10AM, review of the Emergency Power Panel Directory for Panel "GG47E" in Ground Floor Electrical Service Room Y revealed that this panel served both Emergency System-Life Safety Branch loads (e.g., corridor lights, exit signs, stairway lights), Emergency System-Critical Branch loads (e.g., room receptacles), and Equipment System loads (dietary chiller control, air conditioner). In addition, review of the Emergency Power Panel Directory for Panel "GG48E" that was also located in Ground Floor Electrical Service Room Y reveled that it served both Emergency System-Life Safety Branch loads (e.g., emergency lights) and Emergency System-Critical Branch loads (e.g., Pharmacy receptacles).

As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning the above-mentioned conditions.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 4.6.1.2, 19.5.1, 9.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551, NFPA 70-1965, National Electrical Code: Article 700-9, NFPA 70-1968, National Electrical Code: Article 700-9, NFPA 70-1971, National Electrical Code: Article 700-9
10NYCRR, 405.24 (b), 711.2 (a) (1), 711.2 (a) (20)
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1. Based on observations and staff interview during the Federal Recertification 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 the morning of 06/09/16 three (3) unprotected openings caused by missing circuit breakers were noted in Electrical Panel "4F-3", one (1) unprotected opening caused by missing circuit breaker was noted in Electrical Panel "4F1", one (1) unprotected opening caused by missing circuit breaker was noted in Electrical Panel "4F-2E", two (2) unprotected openings caused by missing circuit breakers were noted in Electrical Panel "3F-3", and three (3) unprotected openings caused by missing circuit breakers were noted in Electrical Panel "3F-2E".

b) On the afternoon of 06/09/14 two (2) unprotected openings caused by missing circuit breakers were noted in Electrical Panel "2G-35E" and one (1) unprotected opening caused by missing circuit breaker was noted in Electrical Panel "2G-38E".

c) On 06/10/14 at 9:31AM an electrical junction box that lacked a cover plate on one (1) side of the box was noted above a suspended ceiling in a 1st Floor corridor by the accessory staircase and elevator that serve the A/B Wings.

d) On 06/10/14 at 10:51AM, an electrical extension cord was noted to be hanging down from a ceiling in the Ground Floor Dietary Department Dish Washing Area.

e) On 06/10/13 at 11:15AM an electrical extension cord was noted to be used to supply power to a water cooler in the Ground Floor Central Storage Room.

f) On the morning of 06/10/14 an electrical cord set that served the Poland Spring water refrigerated display case in the Ground Floor Cafeteria was noted to be in disrepair (was frayed near the plug-end of the cord set and needs to be replaced).

g) On 06/10/14 at 1:10PM two (2) electrical junction boxes that lacked cover plates on at least one (1) side of the box were noted above a suspended ceiling in 3rd Floor Room D3026.

h) On the morning of 06/11/14 four (4) duplex electrical receptacles in a corridor in the "On Call" resident building were noted to be cracked/in disrepair and need to be replaced.

As per concurrent interviews with the facility's Director of Facilities Management, he will notify facility Administration concerning these conditions.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-12
10NYCRR, 405.24 (b), 711.2 (a) (1)

2. Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all panelboard circuits and circuit modifications shall be 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.

Findings:

a) On 06/09/14 at 2:47PM the Circuit Directory that was located inside 2nd Floor Emergency Power Electrical Panel "A2LCL1" indicated that Circuits #15, #17, #18, #19, #21, #23, #25, #28 and #29 served "Existing Loads" but failed to identify the specific purpose that these circuits serve. As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

b) On 06/10/14 at 9:34AM the Circuit Directory that was located inside 1st Floor Emergency Power Electrical Panel "A1LCL1" indicated that Circuit #6, served an "Existing Load" but failed to identify the specific purpose that this circuit served.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 384-13
10NYCRR, 405.24 (b), 711.2 (a) (1)

3. Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that all emergency system electrical receptacles in Critical Care Areas were provided with identification that indicates the panelboard and circuit number supplying them.

Findings:

On the morning of 06/10/14 one (1) duplex and two (2) quadruple electrical receptacles in the 1st Floor PACU Suite and one (1) duplex receptacle in the 1st Floor OR Suite Pump Storage Room were noted to lack identification that would indicate the panelboard and circuit number supplying them. As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 517-19 (a)
10NYCRR, 405.24 (b), 711.2 (a) (1)

4. Based on observations and staff interview during the Federal Recertification Survey, the facility failed to ensure that receptacles that may be subject to wetting are provided with ground fault circuit interrupter protection.

Findings:

On 06/10/14 at 9:20AM the electrical cord set for a hydroculator in a 2nd Floor Inpatient Physical Therapy Treatment Area was found to be connected to a standard Hospital Grade receptacle rather than a Hospital Grade ground fault circuit interrupter. As per concurrent interview with the facility's Director of Facilities Management, he will have a Hospital Grade ground fault circuit interrupter installed as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 517-20 (a)
10NYCRR, 405.24 (b), 711.2 (a) (1)

5. Based on observations, record review, and staff interview during the Federal Recertification Survey, the facility failed to ensure that ground fault circuit interrupter receptacles were tested at least once a month in accordance with Manufacturer's instructions.

Findings:

During the survey from 06/09/14 to 06/11/14, ground fault circuit interrupter receptacles located throughout the hospital building were noted to have been labeled by their Manufacturer "TEST MONTHLY". As per interview with the facility's Director of Facilities Management on 06/11/14 at 1:55PM, the facility had not been conducting required monthly testing of these receptacles but will start doing so as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-3 (b)
10NYCRR, 405.24 (b), 711.2 (a) (1)
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Based on observations and interviews during the Federal Recertification Survey, the facility failed to ensure that smoke detectors were installed in each Elevator Machine Room and Elevator Lobby at each floor in accordance with the Fire Fighters' Service Requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators.

Findings:

a) On 06/09/14 at 11:40AM the F-Wing Elevator Machine Room was found to lack a required smoke detector.

b) On 06/10/14 at 8:55AM the E-Wing 3rd Floor Elevator Lobby was found to lack a required smoke detector. As per concurrent interview with the facility's Director of Facilities Management, he will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.3, 9.4.3.2, ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators: 3.11.3, 211.3b
10NYCRR, 405.24 (b), 711.2 (a) (1)