HospitalInspections.org

1) Based on observations, the facility did not ensure that unrated Type 5(000) accessory structures were not placed within ten (10) feet of unprotected window openings in buildings that were not permitted to be combustible.

Findings:

On the morning of 7/7/10, it was noted that a 1-story prefabricated Type 5 (000) building that housed a cardiac catheterization laboratory was approximately five (5) feet from an unprotected window opening to the main hospital building's Intensive Care Unit.

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.1.6


2) Based on observations and record review, the facility did not ensure that all sections of the 4-story Type II (222) Main Building were of Type II (222) construction. Reference is made to a single story section of the building in the vicinity of the Nursing Administration area.

Findings:

a) On 7/9/2010 at 1:56PM, it was noted that fixture protection for the Roof - Ceiling assembly was atypical. The fixture protection consisted of acoustical material (i.e., ceiling tile) placed on the top of the fixture.

b) A review of the current UL Fire Resistance Directory revealed that there were no 1-hour listed Roof-Ceiling assemblies constructed with the noted atypical fixture protection

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.1.6.2
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Based on observations, the facility did not ensure that buildings containing health care occupancies that were of Type II (000) unprotected, non-combustible construction were no more than two (2) stories high.

Findings:

On the afternoon of 7/7/10, observations of the Medical Office Building revealed that it was of Type II (000) construction and three (3) stories in height. Existing health care occupancies that are of Type II (000) unprotected, non-combustible construction are not permitted to be more than two (2) stories in height even when provided with complete sprinkler protection.

42CFR 483.70(a)(1), NFPA 101-2000: 19.1.6
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1) Based on observations, all patient use areas were not separated from the corridor.

Findings:

a) On 7/9/10 at 10:30AM, it was noted that the 1st Floor radiology patient changing area (vicinity X-Ray Room #6) was not separated (i.e., with wall and door) from the corridor.


2. Based on observations, the facility did not ensure that corridor walls in smoke compartments that were not provided with a complete automatic sprinkler system were constructed to provide at least a ?-hour fire resistance rating.

Findings:

a) On 7/8/2010 at 1:00PM, it was noted that there was a 12-inch x 24-inch hole around a plumbing penetration in the corridor wall near Room #217.

b) On the afternoon 7/8/10, an 8-inch x ?-inch gap was noted in a corridor wall in the vicinity of Room #202.

c) On 7/8/10 at 10:10AM, a 2-inch x ?-inch gap was noted at the top of wall joint of a section of corridor wall in the vicinity of a nursing station alcove near Room #240. In addition, portions of the head of wall joint were sealed with unrated material (i.e., drywall compound).

d) On the afternoon of 7/8/10 it was noted that the top-of-wall assemblies (i.e., ceiling/wall junctures) of corridor walls in the 1 North Unit (e.g., vicinity of Rooms #152, #153, #157 and #159) were sealed with non-fire resistance rated material (joint compound).

e) On the afternoon of 7/8/10 an unsealed duct penetration was observed in a 1 North Unit corridor wall (vicinity of the Nurses' Station).

f) On 7/12/10 at 9:29AM, a partially sealed cable penetration was found in a lower-level corridor wall (vicinity of an I.T. closet and North Tower Stair #1).

g) On 7/12/10 at 10:32AM, two (2) unsealed cable and two (2) unsealed plumbing penetrations were found in a lower-level corridor wall (vicinity of the Physicians' Lounge and the Quality Management Performance Improvement Office).

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.6.1, 19.3.6.2
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Based on observations from 7/7/10 -7/13/10, the facility did not ensure that required doors protecting corridor openings were constructed to resist the passage of smoke and were provided with a positive latch capable of keeping the doors closed in the event of a fire or other emergency.

Findings:

a) In several areas, corridor door openings were protected by a pair of doors consisting of an active leaf and an inactive leaf secured at the top and bottom by concealed thumb latches. Pairs of doors shall be provided with automatic flush bolts or similar devices to ensure positive latching. Examples of non-compliant pairs of doors were as follows:

- 1 North Dining Room/Cafeteria Doors
- Lower Level Dialysis Water Treatment Room
- Lower Level Pharmacy

b) On 7/9/10 at 9:51AM, it was noted that the latch on a pair of doors (vicinity Quiet Room) to the Emergency Department suite was not functioning and needed adjustment.

42CFR 483.70(a)(1), NFPA 101-2000: 19-3.6.3
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Based on observations and interview, the facility did not ensure that vision panels and doors in non-fully sprinkler protected smoke compartments were made of fire resistance rated glazing in approved frames.

Findings:

On 7/12/10 at 9:25AM, it a 6-inch circular opening and a 2-inch by 10-inch rectangular opening (i.e., 48 sq. in. total) were noted in a corridor vision panel in the Lower Level Pharmacy. Pass through/communication openings are limited to 20 sq. in.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.6.5
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Based on observations and interview, the facility did not ensure that vertical plumbing between floors in the Medical Office Building were sealed.

Findings:

On 7/7/10 at 12:58PM, an unsealed vertical plumbing penetration was found in the vicinity of the Endoscopy Suite Waiting Room. As per concurrent interview with the facility's Assistant Director of Engineering, the penetration will be sealed as soon as possible.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.1.1, 8.2.5.6
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Based on observations and interview, the facility did not ensure that vertical plumbing between floors were sealed.

Findings:

a) On 7/8/10 at 10:55AM the 2nd floor IT closet (in connecting corridor between 2 North Wing and 2 South Wing) contained a soiled linen and a trash chute. Neither chute is still in use and the doors were screwed shut but were not firestopped along crevices of door frames. A minimum 1-hour fire resistance rating must be provided.

b) On 7/8/10 at 2:15 PM the 1st floor IT closet (in connecting corridor between 1 North Wing and Lobby Area) contained a soiled linen and a trash chute. Neither chute is still in use and the doors were screwed shut but were not firestopped along crevices of door frames. A minimum 1-hour fire resistance rating must be provided.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.1.1, 8.2.5.6
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Based on observations, the facility did not ensure that doors protecting door openings to hazardous areas and to smoke barriers were not held open with unapproved hold open devices.

Findings:

a) On 7/9/10 at 10:20AM, it was noted that the door to a 1st Floor radiology file storage room was held open with a string tie.

b) On 7/9/2010 at 1:56PM, it was noted that the door to a large (i.e., over 100 sq. ft.) sterile supply storage room in the OR suite was held open with a floor level mounted manually operated kick stand type hold open device.

c) On 7/9/10 at 10:09AM a 1st Floor smoke barrier door (door to Chief Radiologic Technician's Office) was held open with a garbage can. The facility's Director of Engineering took immediate corrective action by removing the garbage can.

d) On 7/12/10 at 8:51AM, the door to the lower-level Chronic Dialysis Unit Storage Room was held open with a wooden wedge.

e) On 7/12/10 at 9:20AM and again on 7/13/10 at 10:07AM, the door to the lower-level Mail Room was held open with a wooden wedge.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.2.2.6
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Based on observations and staff interview, the facility did not ensure that all required smoke barrier walls in the Main Hospital Building were constructed to provide at least a ?-hour fire resistance rating. Reference is made to building service equipment penetrations of smoke barrier walls that were unsealed.

Findings:

a) On 7/8/10 at 1:30PM, a 1st Floor smoke barrier wall above cross-corridor doors (vicinity of 1 North Wing TV Room and Room #150) had an unsealed cable penetration and the top-of-wall assembly (i.e., wall/ceiling junctures) was sealed with a non-fire resistance rated material (joint compound).

b) On 7/9/10 at 9:04AM, the top-of-wall assembly (i.e., wall/ceiling junctures) of a 1st Floor smoke barrier wall above cross-corridor doors (vicinity of the Ambulatory Surgery Unit and the Laboratory) was sealed with a non-fire resistance rated material (joint compound).

c) On 7/9/10 at 9:12AM, four (4) plumbing penetrations in a 1st Floor smoke barrier wall (vicinity of an entrance to the Emergency Department) was sealed with a non-fire resistance rated material (joint compound).

d) On 7/9/10 at 10:08AM, a 1st Floor smoke barrier wall above cross-corridor doors (near the Radiology suite) had 4 unsealed plumbing penetrations.

e) On 7/9/10 at 10:11AM, the corrugations in the floor/form unit of the top-of-wall assembly of a 1st Floor smoke barrier wall (vicinity of the Chief Radiologic Technician's office) were not sealed. As per concurrent interview with the facility Director of Engineering, he will have the top-of-wall assembly sealed.

f) On 7/9/10 at 11:19AM, an unsealed cable penetration was found in a 1st Floor smoke barrier wall (vicinity of the rear exit from the NICU).

g) On 7/12/10 at 10:38AM, an unsealed duct penetration, and unsealed conduit penetrations, and several cable penetrations that were sealed with non-fire resistance rated material (i.e., joint compound) were found in a lower-level smoke barrier wall (vicinity of the Nursing Education Office).

h) On 7/12/10 at 10:55AM, an unsealed cable penetration was found in a lower-level smoke barrier wall (vicinity of the Sleep Studies Suite).

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.3.7.3
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Based on observations and staff interview, the facility did not ensure that all required smoke barrier walls in the Medical Office Building were constructed to provide at least a ?-hour fire resistance rating. Reference is made to building service equipment penetrations of smoke barrier walls that were unsealed.

Findings:

On 7/7/10 at 12:55PM, an unsealed cable penetration and an unsealed conduit penetration were found in the smoke barrier wall that serves the Endoscopy Suite (vicinity of the Waiting Room). As per concurrent interview with the facility's Assistant Director of Engineering, the penetrations will be sealed as soon as possible.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.7.3
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1) Based on observations, the facility did not ensure that unsprinklered hazardous areas were separated from all other spaces by at least 1-hour fire resistance rated partitions with all door openings protected with at least ?-hour labeled, self closing, positive latching fire doors.

Findings:

a) On the morning of 7/8/10 it was noted that the door to a 3 North clean utility room (i.e., storage room over 50 sq. ft. in area) was provided with an unlabeled solid core door.

b) On the morning of 7/8/10 it was noted that the head of wall joint on a 2 North clean utility room (vicinity Room #228) was sealed with an unrated material (i.e., drywall compound). Joints, gaps and penetrations shall be sealed with UL listed Joint Systems and Through- Penetration Firestop Systems.

c) On the morning of 7/8/10 it was noted that the door to a 2 North soiled utility room (vicinity Room #227) was provided with an unlabeled solid core door. In addition, the head of wall joint was sealed with an unrated material (i.e., drywall compound).

d) On 7/9/10 at 10:40AM, it was noted that the door to an 80 sq. ft. soiled utility/storage room in the 1st floor CCU was not a labeled fire door.

e) On 7/9/10 at 11:23AM, it was noted that the door opening to an 80 sq. ft. clean utility/storage room on the 1st floor post-partum unit was provided with an unlabeled door with a non-rated plastic vision panel.

f) On 7/9/10 at 11:25AM, it was noted that the door to a 60 sq. ft. soiled utility/storage room in the 1st floor post-partum unit was not a labeled fire door.

g) On 7/8/10 at 9:20AM, an unsealed conduit penetration was found in one (1) of the fire barrier walls the enclosed the kitchen/storage area (vicinity of the Dietary Staff Lounge). As per concurrent interview with the facility's Director of Engineering, the conduit penetration will be sealed appropriately.

h) On 7/8/10 at 9:24AM, an unsealed conduit penetration was found in one (1) of the fire barrier walls that enclosed the kitchen/storage area (vicinity of one of the exits from the kitchen). As per concurrent interview with the facility's Director of Engineering, the conduit penetration will be sealed appropriately.


2) Based on observations, the facility did not ensure that sprinklered hazardous areas were separated from all other spaces by at least smoke resistant partitions with all corridor door openings protected with at least smoke resistant self closing, positive latching fire doors.

Findings:

a) On 7/12/10 at 9:45AM it was noted that the inactive leaf of the pair of doors to the lower-level shop (i.e., Plant Engineering) was not self closing.

b) On 7/12/10 at 10:10AM it was noted that the door to the lower-level shop (i.e., Housekeeping Equipment/Storage Room) was not self closing.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.2.1
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Based on observations, the facility did not ensure that openings into exit stair enclosures were limited to those serving as exit access from normally occupied spaces.

Findings:

On 7/7/10 at 1:30PM it was noted that the door from an unoccupied mechanical room opened into the upper level of the South Wing Stair #1.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.1, 7.1.3.2
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Based on observations, the facility did not ensure that existing exterior exit stairways that serve as part of the means of egress the Medical Office Building were provided with provided handrails on at least one (1) side of the stairs.

Findings:

On 7/7/10 at 11:40AM, an exterior staircase that serves as a portion of the means of egress from the Medical Office Building (vicinity of the connecting corridor between the Medical Office Building and the Main Hospital Building) was found to lack handrails on either side of the stairs.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.2.3, 7.2.2.4.2
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Based on observations, the facility did not ensure that existing exterior exit stairways that serve as part of the means of egress were provided with provided handrails on at least one side of the stairs.

Findings:

On 7/12/10 at 11:12AM, it was noted that a six (6) step flight of stairs at the exit discharge for one (1) of the exits for the lower-level "Cave" (i.e., radiology film storage room) was not provided with a handrail.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.2.3, 7.2.2.4.2
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Based on observations and interview, exit access doors were provided with electronic locks that locked upon the approach of an infant/child with an electronic wrist band with a transmitter. Interviews with facility staff indicated that the locks were for security purposes (e.g., infant abduction) and not the clinical needs of the patients.

Findings:

On 7/9/10 at 11:50AM it was noted that a pair of cross corridor doors in the 1st Floor post-partum unit were provided with an electronic locking device. Concurrent interview with the facility's Director of Security revealed that the locking system was part of an infant abduction system.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.2.2.2.4
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Based on observations and staff interview, the facility did not ensure that sufficient exit discharge lighting was provided and that the lighting was arranged so that the failure of a single light fixture would not leave the area in darkness,

Findings:

a) On 7/7/10 at 10:29AM, a ground floor level exit discharge from the North Wing was found to have two (2) lighting fixtures but only one (1) of them was provided with a light bulb. As per concurrent interview with the facility's Director of Environmental Services, he would have a light bulb installed as soon as possible.

b) On 7/12 at 11:12AM it was noted that the legnthly path of travel between the termination of a exit from the lower-level "Cave" and its associated public way or designated assembly area was not provided with emergency lighting. A single fixture was provided directly above the exit door.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.8, 7.8
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Based on observations, the facility did not ensure that exit discharge lighting at the Medical Office Building was arranged so that the failure of a single light fixture would not leave the area in darkness.

Findings:

a) On 7/7/10 at 11:34AM, the ground floor level exit discharge of one (1) of the exit staircases that serves the Endoscopy Suite (vicinity of the main entrance drive) was found to have only a single light fixture.

b) On 7/7/10 at 1:21PM, the ground floor level exit discharge of one of the exit staircases that serves the Endoscopy Suite (vicinity of the staff parking lot) was found to have only a single light fixture.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.8, 7.8
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Based on observations, the facility did not ensure that emergency illumination at the Medical Office Building was arranged so that there would not be a delay of more than ten (10) seconds when changing from the normal power source to the emergency power source.

Findings:

On 7/7/10 at 11:32AM, the exit discharge from an exit to grade from the lower-level of the Medical Office Building was found to be illuminated by a single bulb High Intensity Discharge (HID) lighting fixture. HID lighting fixtures usually take more than ten (10) seconds to start once they are energized.

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.2.9, 7.9.1.2, NFPA 7-1999 National Electrical Code: Article 700-12, 700-16
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Based on observations, the facility did not ensure that emergency illumination at the main hospital building was arranged so that there would not be a delay of more than ten (10) seconds when changing from the normal power source to the emergency power source.

Findings:

a) On 7/7/10 at 10:42AM, the means of egress from the exit discharge to the public way (vicinity of exit from the MRI unit and the temporary cardiac catheterization unit) was found to be illuminated by High Intensity Discharge (HID) lighting fixtures. HID lighting fixtures usually take more than ten (10) seconds to start once they are energized.

b) On 7/7/10 at 11:02AM, the exit discharge from an exit to grade (vicinity of the Ambulatory Surgery Unit) was found to be illuminated by High Intensity Discharge (HID) lighting fixtures. HID lighting fixtures usually take more than ten (10) seconds to start once they are energized.

c) On 7/7/10 at 11:20 AM, the exit discharge from an exit to grade (vicinity of the Operating Room unit) was found to be illuminated by High Intensity Discharge (HID) lighting fixtures. HID lighting fixtures usually take more than ten (10) seconds to start once they are energized.

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.2.9, 7.9.1.2, NFPA 7-1999 National Electrical Code: Article 700-12, 700-16
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Based on observations and staff interview, the facility did not ensure that exit identification signs were installed in accordance with Section 7.10.1. Section 7.10 requires that exits shall be marked by an approved sign readily visible from any direction of exit access.

Findings:

On 7/8/10 at 1:49PM, an exterior exit gate that serves as a means of egress from the 1 North Psychiatric Unit's exterior courtyard area was found to lack an exit identification sign. As per concurrent interview with the facility's Director of Engineering, he would have an exit sign installed as soon as possible.

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.2.10.1, 7.10
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Based on observations and staff interview, the facility did not ensure that the required fire alarm system in the Medical Office Building was installed in accordance with all of the requirements of NFPA 72, National Fire Alarm Code.

Findings:

On 7/7/10 at 1:24PM, a designated exit door to the outside of the building (vicinity of the connecting corridor between the Medical Office Building and the Main Hospital Building) was found to lack a manual fire alarm pull station within five (5) feet of the door. As per concurrent interview with facility's Assistant Director of Engineering he will inform the Director of Engineering of this issue.

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 9.6.1.4, NFPA 72-1999 National Fire Alarm Code: 2-8.2.2
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Based on record reviews and interview during the recertification survey, the facility did not ensure that all fire protection systems were maintained, inspected, and tested in accordance with the requirements found in NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. This has the potential for more than minimal harm to residents but no actual harm has occurred.

Findings:

On 7/12/10 at 2:41PM, review of automatic fire sprinkler maintenance records revealed that there were no records that required testing and inspection of automatic sprinkler system alarm valves, check valves, and pressure gauges were being performed at least once every five (5) years. As per concurrent interview with the facility's Assistant Director of Engineering, the vendor who used to maintain the automatic sprinkler system was doing all of the required maintenance on the sprinkler system and had recently been replaced and that he would ensure that the required inspections and tests are performed as soon as possible.

42CFR 483.70(a)(1), 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: 9-1, 9-4.2, Table 9-1
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Metal containers with self-closing covers into which ashtrays could be emptied with either not provided or when provided were not maintained in good condition in the outdoor smoking area that serves the 1 North Wing Psychiatric Unit.

Findings:

a) On 7/8/10 at 1:45PM it was noted that three (3) of three (3) metal containers with self-closing covers were in disrepair. Two (2) were missing at least one (1) of two (2) self-closing doors/covers and one was missing both of its self-closing covers/doors.

b) On 7/8/10 at 1:47PM it was noted that a non-metallic receptacle that also lacked self-closing covers (i.e., a plastic Rubbermaid 3958 brand refuse container) was found to also be used to empty ashtrays into. Cigarette butts and ashes were noticed mixed with other combustible waste in the combustible waste container.

42CFR 483.70(a)(1), NFPA 101-2000: 19.7.4
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Based on observations and staff interview, the facility did not ensure that air handling equipment rooms were separated from other use areas by at least 1-hour fire resistance rated barriers.

Findings:

On 7/12/10 at 9:49AM, three (3) unsealed cable penetrations were found in the fire barrier wall between a lower-level air handling equipment room and the Engineering Department Workshop. As per concurrent interview with the facility's Director of Engineering, the penetrations will be sealed as soon as possible.

42CFR 483.70(a)(1), NFPA 101-2000 life Safety Code: 19.5.2.1, 9.2, NFPA 90A
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Based on record review, supply air systems in excess of 2000 cfm (i.e., 5 Ton) that served the MOB building were not provided with automatic fan shut down in accordance with NFPA 90 A.

Findings:

A review of the specifications for the two (2) 20-75 Ton rooftop air conditioning units revealed that automatic fan shut down was not provided.

42CFR 483.70(a)(1), NFPA 101-2000: 19.5.2.1, 9.2. NFPA 90A
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Based on observations and staff interviews, the facility did not ensure that fire suppression systems in food preparation areas were properly maintained in accordance with applicable NFPA standards.

Findings:

a) On 7/8/10 at 8:54AM, three (3) out of five (5) of the fire suppression system discharge nozzle blow-off caps of the fire suppression system in the kitchen were found to be missing. In addition, four (4) out of five (5) of the fire suppression system discharge nozzle blow-off caps of the fire suppression system in the kitchen were found to be dust laden. As per concurrent interview with the facility's Director of Engineering, he will have the discharge nozzles cleaned and the blow-off caps replaced as soon as possible.

b) On 7/8/10 at 9:10AM, one (1) out of two (2) of the fire suppression system discharge nozzle blow-off caps of the fire suppression system in the "Rio Cafe" cafeteria servery/food preparation area were found to be missing. In addition, two (2) out of two (2) of the fire suppression system discharge nozzle blow-off caps of the fire suppression system in the kitchen were found to be dust laden. As per concurrent interview with the facility's Director of Engineering, he will have the discharge nozzles cleaned and the blow-off caps replaced as soon as possible.

c) On 7/8/10 at 9:15AM, four (4) out of four (4) of the fire suppression system discharge nozzle blow-off caps of the fire suppression system in the "Rio Cafe" cafeteria kitchen/food preparation area were found to be missing. In addition, four (4) out of four (4) of the fire suppression system discharge nozzle blow-off caps of the fire suppression system in the kitchen were found to be heavily grease and dust laden. As per concurrent interview with the facility's Director of Engineering, he will have the discharge nozzles cleaned and the blow-off caps replaced as soon as possible.

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.3.2.6, 9.2.3, NFPA 96-1998, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations: 8-2, NFPA 17A-1998 Standard for Wet Chemical Extinguishing Systems: 5-2
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Based on observations and staff interview, the facility did not ensure that required separation distances between bulk oxygen systems and other structures and vehicles were maintained in accordance with applicable NFPA standards.

Findings:

a) On 7/7/10 at 11:08AM, a combustible modular building (e.g., the Infection Control Office) was found to be less than fifty (50) feet (e.g., thirty-eight (38) feet) from exposed piping of the bulk oxygen system.

b) On 7/7/10 at 11:11AM, combustible building (e.g., the road salt storage shed) was found to be less than fifty (50) feet (e.g., forty-two (42) feet) from exposed piping of the bulk oxygen system.

c) On 7/7/10 at 11:12AM, a vehicle (White Chevrolet Blazer) was found to be parked less than ten (10) feet (e.g., seven (7) feet) from the bulk oxygen system. As per concurrent interview with the facility's Director of Engineering, he would have the car moved as soon as possible.

d) On 7/13/10 at 8:20AM a pick-up truck was noted parked eight (8) feet from the bulk oxygen unit.

42CFR 483.70(a)(1), NFPA 99-1999: 4-3.1.1.2 (a) (10b), NFPA 50-1996: 2-2
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1) Based on observations and staff interview, the facility did not ensure that the arrangement of all means of egress in the Main Building was in accordance with NFPA 101-2000: 19.2.5.

Findings:

a) On the morning of 7/8/10, it was noted that a required means of exit access from the kitchen was through the Main Building "Rio Cafe" cafeteria food servery and seating area. Corridors shall provide access to exits without passing through any intervening rooms or spaces other than corridors or lobbies.

b) On 7/8/10 at 8:41AM, a folding metal security gate with a padlock was found in the means of egress from the Dietary Dry Goods Storage Room. As per concurrent interview with the facility'S Director of Engineering, he would have the padlock and gate removed as soon as possible.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.5.9, 19.2.5.2, 19.2.5.8


2) Based on observations, interviews, and record review, the facility did not ensure that fire hydrants on their property that they owned and were responsible for maintaining were maintained in accordance with the requirements of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Findings:

On 7/7/10 at 10:25AM bushes/vegetation were found to be only three (3) inches from one two and one-half (2 ?) inch hose outlet and directly against another two and one-half (2 ?) inch hose outlet of a fire hydrant on the hospital campus (vicinity of the main entrance drive). Access to hose connections on fire hydrants must be maintained. A clear space of at least thirty (30) inches shall be maintained around fire hydrant to ensure that they are accessible to fire service personnel. As per concurrent interview with the facility's Director of Environmental Services, he will have the bushes trimmed away from the fire hydrant so that firefighter access to it is not blocked.

42CFR 483.70(a)(1), NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems:4-2.2.4, 4-3.2, 4-3.4.3.1


3) Based on observations the facility did not ensure that the arrangement of all means of egress was in accordance with NFPA 101- 2000: 19.2.5.

Findings:

On 7/9/10 it was noted that travel distance to an exit access door from the OR suite involved two (2) room travel that was in excess of fifty (50) feet total distance. For example, the travel distance from the far point in OR #3 was eighty-five (85) feet and the distance from the far point in OR #6 was eighty (80) feet.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.5


4) Based on observations and record review (i.e., panelboard schedule) the Main Building was not provided with a Type 1 Essential Electrical System installed in accordance with NFPA 99.

Findings:

a) The wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System. For example:

- Emergency panel EC1B-ASU served both Equipment System circuits (e.g., condensate tank) and Emergency System circuits ( e.g., exit lights).

- 1st Floor emergency panel EM1B-1 served both Equipment System circuits (e.g., multiple exhaust fans) and Emergency System circuits (e.g., nurse call).

- 1st Floor emergency panel EM1A served Equipment System circuits (e.g., multiple heating units), Emergency System-Critical Branch circuits (e.g., nurse call) and Emergency System -Life Safety Code (i.e., Elevator lighting).

-1st Floor emergency panel EM1A served Equipment System circuits ( e.g., roof exhaust fan), Emergency System-Critical Branch circuits (e.g., Lab receptacles, Physical Therapy receptacles) and Emergency System -Life Safety Code (i.e., Medical Gas Alarm Panel).

b) The wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch. For example:

- Emergency panel LP-EM-3 (3S) served both Emergency System - Life Safety Branch circuits (e.g., medical gas alarm, corridor lighting) and Emergency System - Critical Branch circuits (e.g., nurse call system).

- Emergency panel EC1B-ASU served both Emergency System - Life Safety Branch circuits (e.g., exit lights) and Emergency System - Critical Branch circuits (e.g., lab receptacles).

- Emergency panel E1A served both Emergency System - Life Safety Branch circuits (e.g., exit light) and Emergency System - Critical Branch circuits (e.g., receptacles).

- Emergency panel EC1B served both Emergency System - Life Safety Branch circuits (e.g., Medical Gas Alarm Panel) and Emergency System - Critical Branch circuits (e.g., receptacles, nurse call).

- Emergency panel LP1LS served both Emergency System - Life Safety Branch circuits (e.g., exit lights, medical gas alarm panel) and Emergency System - Critical Branch circuits (e.g., Cysto warming unit).

- Emergency panel LCEOR7 served both Emergency System - Life Safety Branch circuits (e.g., medical gas alarm panel) and Emergency System - Critical Branch circuits (e.g., receptacles, sterilizer, laser).

10 NYCRR, 711.2(a)(26), NFPA 99 - 1999: Ch 3, NFPA 70: Article 517


5) Based on observations on the morning of 7/7/10 all ramps that served as portions of a means of egress were not in accordance with NFPA 101- 2010: 7.2.5 Ramps.

Findings:

A ramp that served as a portion of a means of egress from the loading dock area was not provided with handrails.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.2, 19.2.2.6, 7.2.5
.

Based on observations, record review (i.e., panelboard schedule), and staff interview, the facility did not ensure that the Medical Office Building Endoscopy suite was not provided with a Type 1 Essential Electrical System installed in accordance with NFPA 99.

Findings:

a) Based on interviews with the Endoscopy Suite Nurse Manager on 7/7/10 at 1:53PM, it was determined that at least four (4) inpatients have customary access to the Endoscopy Unit at any one time and that invasive procedures are performed (e.g., diagnostic colonoscopies). NFPA 99, Standard for Health Care Facilities requires that a Type 1 Essential Electrical System be provided.

b) The wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System and the wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch. For example, on 7/7/10 at 1:12PM, it was noted that the Emergency Power Panel ELPLL in the lower-level of the Medical Office Building served items from the Emergency System - Life Safety Branch (i.e., Medical Gas Alarm Panel), Emergency System - Critical Branch (i.e., nurse call system and holding area receptacles) and the Equipment System (i.e., Boiler 32).

42CFR 483.70(a)(1), NFPA 99 - 1999 Standard for Health Care Facilities: 12-3.3.2, Ch 3, NFPA 70: Article 517

Based on observations, the facility failed to use Relocatable Power Taps (RPTs) in a safe manner. Reference is made to dangling RPTs that put excessive strain on the power cords that were plugged into the RPT.

Findings:

a) On 7/8/10 at 10:27AM a Relocatable Power Tap was noted dangling six (6) inches above the floor at a 2nd Floor Nursing Station. Two (2) computer related devices were plugged into the power tap.

b) On 7/8/10 at 11:05AM the RPT used to supply power to a Room Service Meal Ticket Printing Machine in the kitchen area was noted dangling down from the ceiling.

42CFR 483.70(a)(1), NFPA 101-2000: 19.5.1, NFPA 70
.

Based on observations and interview the elevator serving the 4-story South Tower was not provided with Phase I smoke detector automatic recall.

Findings:

During a fire drill that was observed on 7/9/10 at 2:30PM, it was noted that the main elevator was not provided with automatic recall. Concurrent interview with the facility's Security Director revealed that Phase 1 automatic recall was not provided.

42CFR 483.70(a)(1), NFPA 101-2000: 19.5.3, 9.4.3.2
.

Based on observations, Alcohol Based Hand Rubs (ABHRs) were not installed in accordance with 19.3.2.7 - Alcohol-Based Hand Rub dispensers.

Findings:

a) On the morning of 7/9/10 it was noted that ABHRs were installed in carpeted areas in smoke compartments that were not provided with a complete automatic sprinkler system. Examples include ABHRs in the Gift Shop, Administrative Office area, etc.

b) On 7/8/10 at 2:27PM it was noted that an ABHR was installed directly above an electrical receptacle in the Ambulatory Surgery Unit.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.2.7
.

1) Based on observations, the facility did not ensure that unrated Type 5(000) accessory structures were not placed within ten (10) feet of unprotected window openings in buildings that were not permitted to be combustible.

Findings:

On the morning of 7/7/10, it was noted that a 1-story prefabricated Type 5 (000) building that housed a cardiac catheterization laboratory was approximately five (5) feet from an unprotected window opening to the main hospital building's Intensive Care Unit.

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.1.6


2) Based on observations and record review, the facility did not ensure that all sections of the 4-story Type II (222) Main Building were of Type II (222) construction. Reference is made to a single story section of the building in the vicinity of the Nursing Administration area.

Findings:

a) On 7/9/2010 at 1:56PM, it was noted that fixture protection for the Roof - Ceiling assembly was atypical. The fixture protection consisted of acoustical material (i.e., ceiling tile) placed on the top of the fixture.

b) A review of the current UL Fire Resistance Directory revealed that there were no 1-hour listed Roof-Ceiling assemblies constructed with the noted atypical fixture protection

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.1.6.2
.

Based on observations, the facility did not ensure that buildings containing health care occupancies that were of Type II (000) unprotected, non-combustible construction were no more than two (2) stories high.

Findings:

On the afternoon of 7/7/10, observations of the Medical Office Building revealed that it was of Type II (000) construction and three (3) stories in height. Existing health care occupancies that are of Type II (000) unprotected, non-combustible construction are not permitted to be more than two (2) stories in height even when provided with complete sprinkler protection.

42CFR 483.70(a)(1), NFPA 101-2000: 19.1.6
.

1) Based on observations, all patient use areas were not separated from the corridor.

Findings:

a) On 7/9/10 at 10:30AM, it was noted that the 1st Floor radiology patient changing area (vicinity X-Ray Room #6) was not separated (i.e., with wall and door) from the corridor.


2. Based on observations, the facility did not ensure that corridor walls in smoke compartments that were not provided with a complete automatic sprinkler system were constructed to provide at least a ?-hour fire resistance rating.

Findings:

a) On 7/8/2010 at 1:00PM, it was noted that there was a 12-inch x 24-inch hole around a plumbing penetration in the corridor wall near Room #217.

b) On the afternoon 7/8/10, an 8-inch x ?-inch gap was noted in a corridor wall in the vicinity of Room #202.

c) On 7/8/10 at 10:10AM, a 2-inch x ?-inch gap was noted at the top of wall joint of a section of corridor wall in the vicinity of a nursing station alcove near Room #240. In addition, portions of the head of wall joint were sealed with unrated material (i.e., drywall compound).

d) On the afternoon of 7/8/10 it was noted that the top-of-wall assemblies (i.e., ceiling/wall junctures) of corridor walls in the 1 North Unit (e.g., vicinity of Rooms #152, #153, #157 and #159) were sealed with non-fire resistance rated material (joint compound).

e) On the afternoon of 7/8/10 an unsealed duct penetration was observed in a 1 North Unit corridor wall (vicinity of the Nurses' Station).

f) On 7/12/10 at 9:29AM, a partially sealed cable penetration was found in a lower-level corridor wall (vicinity of an I.T. closet and North Tower Stair #1).

g) On 7/12/10 at 10:32AM, two (2) unsealed cable and two (2) unsealed plumbing penetrations were found in a lower-level corridor wall (vicinity of the Physicians' Lounge and the Quality Management Performance Improvement Office).

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.6.1, 19.3.6.2
.

Based on observations from 7/7/10 -7/13/10, the facility did not ensure that required doors protecting corridor openings were constructed to resist the passage of smoke and were provided with a positive latch capable of keeping the doors closed in the event of a fire or other emergency.

Findings:

a) In several areas, corridor door openings were protected by a pair of doors consisting of an active leaf and an inactive leaf secured at the top and bottom by concealed thumb latches. Pairs of doors shall be provided with automatic flush bolts or similar devices to ensure positive latching. Examples of non-compliant pairs of doors were as follows:

- 1 North Dining Room/Cafeteria Doors
- Lower Level Dialysis Water Treatment Room
- Lower Level Pharmacy

b) On 7/9/10 at 9:51AM, it was noted that the latch on a pair of doors (vicinity Quiet Room) to the Emergency Department suite was not functioning and needed adjustment.

42CFR 483.70(a)(1), NFPA 101-2000: 19-3.6.3
.

Based on observations and interview, the facility did not ensure that vision panels and doors in non-fully sprinkler protected smoke compartments were made of fire resistance rated glazing in approved frames.

Findings:

On 7/12/10 at 9:25AM, it a 6-inch circular opening and a 2-inch by 10-inch rectangular opening (i.e., 48 sq. in. total) were noted in a corridor vision panel in the Lower Level Pharmacy. Pass through/communication openings are limited to 20 sq. in.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.6.5
.

Based on observations and interview, the facility did not ensure that vertical plumbing between floors in the Medical Office Building were sealed.

Findings:

On 7/7/10 at 12:58PM, an unsealed vertical plumbing penetration was found in the vicinity of the Endoscopy Suite Waiting Room. As per concurrent interview with the facility's Assistant Director of Engineering, the penetration will be sealed as soon as possible.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.1.1, 8.2.5.6
.

Based on observations and interview, the facility did not ensure that vertical plumbing between floors were sealed.

Findings:

a) On 7/8/10 at 10:55AM the 2nd floor IT closet (in connecting corridor between 2 North Wing and 2 South Wing) contained a soiled linen and a trash chute. Neither chute is still in use and the doors were screwed shut but were not firestopped along crevices of door frames. A minimum 1-hour fire resistance rating must be provided.

b) On 7/8/10 at 2:15 PM the 1st floor IT closet (in connecting corridor between 1 North Wing and Lobby Area) contained a soiled linen and a trash chute. Neither chute is still in use and the doors were screwed shut but were not firestopped along crevices of door frames. A minimum 1-hour fire resistance rating must be provided.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.1.1, 8.2.5.6
.

Based on observations, the facility did not ensure that doors protecting door openings to hazardous areas and to smoke barriers were not held open with unapproved hold open devices.

Findings:

a) On 7/9/10 at 10:20AM, it was noted that the door to a 1st Floor radiology file storage room was held open with a string tie.

b) On 7/9/2010 at 1:56PM, it was noted that the door to a large (i.e., over 100 sq. ft.) sterile supply storage room in the OR suite was held open with a floor level mounted manually operated kick stand type hold open device.

c) On 7/9/10 at 10:09AM a 1st Floor smoke barrier door (door to Chief Radiologic Technician's Office) was held open with a garbage can. The facility's Director of Engineering took immediate corrective action by removing the garbage can.

d) On 7/12/10 at 8:51AM, the door to the lower-level Chronic Dialysis Unit Storage Room was held open with a wooden wedge.

e) On 7/12/10 at 9:20AM and again on 7/13/10 at 10:07AM, the door to the lower-level Mail Room was held open with a wooden wedge.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.2.2.6
.

Based on observations and staff interview, the facility did not ensure that all required smoke barrier walls in the Main Hospital Building were constructed to provide at least a ?-hour fire resistance rating. Reference is made to building service equipment penetrations of smoke barrier walls that were unsealed.

Findings:

a) On 7/8/10 at 1:30PM, a 1st Floor smoke barrier wall above cross-corridor doors (vicinity of 1 North Wing TV Room and Room #150) had an unsealed cable penetration and the top-of-wall assembly (i.e., wall/ceiling junctures) was sealed with a non-fire resistance rated material (joint compound).

b) On 7/9/10 at 9:04AM, the top-of-wall assembly (i.e., wall/ceiling junctures) of a 1st Floor smoke barrier wall above cross-corridor doors (vicinity of the Ambulatory Surgery Unit and the Laboratory) was sealed with a non-fire resistance rated material (joint compound).

c) On 7/9/10 at 9:12AM, four (4) plumbing penetrations in a 1st Floor smoke barrier wall (vicinity of an entrance to the Emergency Department) was sealed with a non-fire resistance rated material (joint compound).

d) On 7/9/10 at 10:08AM, a 1st Floor smoke barrier wall above cross-corridor doors (near the Radiology suite) had 4 unsealed plumbing penetrations.

e) On 7/9/10 at 10:11AM, the corrugations in the floor/form unit of the top-of-wall assembly of a 1st Floor smoke barrier wall (vicinity of the Chief Radiologic Technician's office) were not sealed. As per concurrent interview with the facility Director of Engineering, he will have the top-of-wall assembly sealed.

f) On 7/9/10 at 11:19AM, an unsealed cable penetration was found in a 1st Floor smoke barrier wall (vicinity of the rear exit from the NICU).

g) On 7/12/10 at 10:38AM, an unsealed duct penetration, and unsealed conduit penetrations, and several cable penetrations that were sealed with non-fire resistance rated material (i.e., joint compound) were found in a lower-level smoke barrier wall (vicinity of the Nursing Education Office).

h) On 7/12/10 at 10:55AM, an unsealed cable penetration was found in a lower-level smoke barrier wall (vicinity of the Sleep Studies Suite).

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.3.7.3
.

Based on observations and staff interview, the facility did not ensure that all required smoke barrier walls in the Medical Office Building were constructed to provide at least a ?-hour fire resistance rating. Reference is made to building service equipment penetrations of smoke barrier walls that were unsealed.

Findings:

On 7/7/10 at 12:55PM, an unsealed cable penetration and an unsealed conduit penetration were found in the smoke barrier wall that serves the Endoscopy Suite (vicinity of the Waiting Room). As per concurrent interview with the facility's Assistant Director of Engineering, the penetrations will be sealed as soon as possible.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.7.3
.

1) Based on observations, the facility did not ensure that unsprinklered hazardous areas were separated from all other spaces by at least 1-hour fire resistance rated partitions with all door openings protected with at least ?-hour labeled, self closing, positive latching fire doors.

Findings:

a) On the morning of 7/8/10 it was noted that the door to a 3 North clean utility room (i.e., storage room over 50 sq. ft. in area) was provided with an unlabeled solid core door.

b) On the morning of 7/8/10 it was noted that the head of wall joint on a 2 North clean utility room (vicinity Room #228) was sealed with an unrated material (i.e., drywall compound). Joints, gaps and penetrations shall be sealed with UL listed Joint Systems and Through- Penetration Firestop Systems.

c) On the morning of 7/8/10 it was noted that the door to a 2 North soiled utility room (vicinity Room #227) was provided with an unlabeled solid core door. In addition, the head of wall joint was sealed with an unrated material (i.e., drywall compound).

d) On 7/9/10 at 10:40AM, it was noted that the door to an 80 sq. ft. soiled utility/storage room in the 1st floor CCU was not a labeled fire door.

e) On 7/9/10 at 11:23AM, it was noted that the door opening to an 80 sq. ft. clean utility/storage room on the 1st floor post-partum unit was provided with an unlabeled door with a non-rated plastic vision panel.

f) On 7/9/10 at 11:25AM, it was noted that the door to a 60 sq. ft. soiled utility/storage room in the 1st floor post-partum unit was not a labeled fire door.

g) On 7/8/10 at 9:20AM, an unsealed conduit penetration was found in one (1) of the fire barrier walls the enclosed the kitchen/storage area (vicinity of the Dietary Staff Lounge). As per concurrent interview with the facility's Director of Engineering, the conduit penetration will be sealed appropriately.

h) On 7/8/10 at 9:24AM, an unsealed conduit penetration was found in one (1) of the fire barrier walls that enclosed the kitchen/storage area (vicinity of one of the exits from the kitchen). As per concurrent interview with the facility's Director of Engineering, the conduit penetration will be sealed appropriately.


2) Based on observations, the facility did not ensure that sprinklered hazardous areas were separated from all other spaces by at least smoke resistant partitions with all corridor door openings protected with at least smoke resistant self closing, positive latching fire doors.

Findings:

a) On 7/12/10 at 9:45AM it was noted that the inactive leaf of the pair of doors to the lower-level shop (i.e., Plant Engineering) was not self closing.

b) On 7/12/10 at 10:10AM it was noted that the door to the lower-level shop (i.e., Housekeeping Equipment/Storage Room) was not self closing.

42CFR 483.70(a)(1), NFPA 101-2000: 19.3.2.1
.

Based on observations, the facility did not ensure that openings into exit stair enclosures were limited to those serving as exit access from normally occupied spaces.

Findings:

On 7/7/10 at 1:30PM it was noted that the door from an unoccupied mechanical room opened into the upper level of the South Wing Stair #1.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.1, 7.1.3.2
.

Based on observations, the facility did not ensure that existing exterior exit stairways that serve as part of the means of egress the Medical Office Building were provided with provided handrails on at least one (1) side of the stairs.

Findings:

On 7/7/10 at 11:40AM, an exterior staircase that serves as a portion of the means of egress from the Medical Office Building (vicinity of the connecting corridor between the Medical Office Building and the Main Hospital Building) was found to lack handrails on either side of the stairs.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.2.3, 7.2.2.4.2
.

Based on observations, the facility did not ensure that existing exterior exit stairways that serve as part of the means of egress were provided with provided handrails on at least one side of the stairs.

Findings:

On 7/12/10 at 11:12AM, it was noted that a six (6) step flight of stairs at the exit discharge for one (1) of the exits for the lower-level "Cave" (i.e., radiology film storage room) was not provided with a handrail.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.2.3, 7.2.2.4.2
.

Based on observations and interview, exit access doors were provided with electronic locks that locked upon the approach of an infant/child with an electronic wrist band with a transmitter. Interviews with facility staff indicated that the locks were for security purposes (e.g., infant abduction) and not the clinical needs of the patients.

Findings:

On 7/9/10 at 11:50AM it was noted that a pair of cross corridor doors in the 1st Floor post-partum unit were provided with an electronic locking device. Concurrent interview with the facility's Director of Security revealed that the locking system was part of an infant abduction system.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.2.2.2.4
.

Based on observations and staff interview, the facility did not ensure that sufficient exit discharge lighting was provided and that the lighting was arranged so that the failure of a single light fixture would not leave the area in darkness,

Findings:

a) On 7/7/10 at 10:29AM, a ground floor level exit discharge from the North Wing was found to have two (2) lighting fixtures but only one (1) of them was provided with a light bulb. As per concurrent interview with the facility's Director of Environmental Services, he would have a light bulb installed as soon as possible.

b) On 7/12 at 11:12AM it was noted that the legnthly path of travel between the termination of a exit from the lower-level "Cave" and its associated public way or designated assembly area was not provided with emergency lighting. A single fixture was provided directly above the exit door.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.8, 7.8
.

Based on observations, the facility did not ensure that exit discharge lighting at the Medical Office Building was arranged so that the failure of a single light fixture would not leave the area in darkness.

Findings:

a) On 7/7/10 at 11:34AM, the ground floor level exit discharge of one (1) of the exit staircases that serves the Endoscopy Suite (vicinity of the main entrance drive) was found to have only a single light fixture.

b) On 7/7/10 at 1:21PM, the ground floor level exit discharge of one of the exit staircases that serves the Endoscopy Suite (vicinity of the staff parking lot) was found to have only a single light fixture.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.8, 7.8
.

Based on observations, the facility did not ensure that emergency illumination at the Medical Office Building was arranged so that there would not be a delay of more than ten (10) seconds when changing from the normal power source to the emergency power source.

Findings:

On 7/7/10 at 11:32AM, the exit discharge from an exit to grade from the lower-level of the Medical Office Building was found to be illuminated by a single bulb High Intensity Discharge (HID) lighting fixture. HID lighting fixtures usually take more than ten (10) seconds to start once they are energized.

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.2.9, 7.9.1.2, NFPA 7-1999 National Electrical Code: Article 700-12, 700-16
.

Based on observations, the facility did not ensure that emergency illumination at the main hospital building was arranged so that there would not be a delay of more than ten (10) seconds when changing from the normal power source to the emergency power source.

Findings:

a) On 7/7/10 at 10:42AM, the means of egress from the exit discharge to the public way (vicinity of exit from the MRI unit and the temporary cardiac catheterization unit) was found to be illuminated by High Intensity Discharge (HID) lighting fixtures. HID lighting fixtures usually take more than ten (10) seconds to start once they are energized.

b) On 7/7/10 at 11:02AM, the exit discharge from an exit to grade (vicinity of the Ambulatory Surgery Unit) was found to be illuminated by High Intensity Discharge (HID) lighting fixtures. HID lighting fixtures usually take more than ten (10) seconds to start once they are energized.

c) On 7/7/10 at 11:20 AM, the exit discharge from an exit to grade (vicinity of the Operating Room unit) was found to be illuminated by High Intensity Discharge (HID) lighting fixtures. HID lighting fixtures usually take more than ten (10) seconds to start once they are energized.

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.2.9, 7.9.1.2, NFPA 7-1999 National Electrical Code: Article 700-12, 700-16
.

Based on observations and staff interview, the facility did not ensure that exit identification signs were installed in accordance with Section 7.10.1. Section 7.10 requires that exits shall be marked by an approved sign readily visible from any direction of exit access.

Findings:

On 7/8/10 at 1:49PM, an exterior exit gate that serves as a means of egress from the 1 North Psychiatric Unit's exterior courtyard area was found to lack an exit identification sign. As per concurrent interview with the facility's Director of Engineering, he would have an exit sign installed as soon as possible.

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.2.10.1, 7.10
.

Based on observations and staff interview, the facility did not ensure that the required fire alarm system in the Medical Office Building was installed in accordance with all of the requirements of NFPA 72, National Fire Alarm Code.

Findings:

On 7/7/10 at 1:24PM, a designated exit door to the outside of the building (vicinity of the connecting corridor between the Medical Office Building and the Main Hospital Building) was found to lack a manual fire alarm pull station within five (5) feet of the door. As per concurrent interview with facility's Assistant Director of Engineering he will inform the Director of Engineering of this issue.

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 9.6.1.4, NFPA 72-1999 National Fire Alarm Code: 2-8.2.2
.

Based on record reviews and interview during the recertification survey, the facility did not ensure that all fire protection systems were maintained, inspected, and tested in accordance with the requirements found in NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. This has the potential for more than minimal harm to residents but no actual harm has occurred.

Findings:

On 7/12/10 at 2:41PM, review of automatic fire sprinkler maintenance records revealed that there were no records that required testing and inspection of automatic sprinkler system alarm valves, check valves, and pressure gauges were being performed at least once every five (5) years. As per concurrent interview with the facility's Assistant Director of Engineering, the vendor who used to maintain the automatic sprinkler system was doing all of the required maintenance on the sprinkler system and had recently been replaced and that he would ensure that the required inspections and tests are performed as soon as possible.

42CFR 483.70(a)(1), 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: 9-1, 9-4.2, Table 9-1
.

Metal containers with self-closing covers into which ashtrays could be emptied with either not provided or when provided were not maintained in good condition in the outdoor smoking area that serves the 1 North Wing Psychiatric Unit.

Findings:

a) On 7/8/10 at 1:45PM it was noted that three (3) of three (3) metal containers with self-closing covers were in disrepair. Two (2) were missing at least one (1) of two (2) self-closing doors/covers and one was missing both of its self-closing covers/doors.

b) On 7/8/10 at 1:47PM it was noted that a non-metallic receptacle that also lacked self-closing covers (i.e., a plastic Rubbermaid 3958 brand refuse container) was found to also be used to empty ashtrays into. Cigarette butts and ashes were noticed mixed with other combustible waste in the combustible waste container.

42CFR 483.70(a)(1), NFPA 101-2000: 19.7.4
.

Based on observations and staff interview, the facility did not ensure that air handling equipment rooms were separated from other use areas by at least 1-hour fire resistance rated barriers.

Findings:

On 7/12/10 at 9:49AM, three (3) unsealed cable penetrations were found in the fire barrier wall between a lower-level air handling equipment room and the Engineering Department Workshop. As per concurrent interview with the facility's Director of Engineering, the penetrations will be sealed as soon as possible.

42CFR 483.70(a)(1), NFPA 101-2000 life Safety Code: 19.5.2.1, 9.2, NFPA 90A
.

Based on record review, supply air systems in excess of 2000 cfm (i.e., 5 Ton) that served the MOB building were not provided with automatic fan shut down in accordance with NFPA 90 A.

Findings:

A review of the specifications for the two (2) 20-75 Ton rooftop air conditioning units revealed that automatic fan shut down was not provided.

42CFR 483.70(a)(1), NFPA 101-2000: 19.5.2.1, 9.2. NFPA 90A
.

Based on observations and staff interviews, the facility did not ensure that fire suppression systems in food preparation areas were properly maintained in accordance with applicable NFPA standards.

Findings:

a) On 7/8/10 at 8:54AM, three (3) out of five (5) of the fire suppression system discharge nozzle blow-off caps of the fire suppression system in the kitchen were found to be missing. In addition, four (4) out of five (5) of the fire suppression system discharge nozzle blow-off caps of the fire suppression system in the kitchen were found to be dust laden. As per concurrent interview with the facility's Director of Engineering, he will have the discharge nozzles cleaned and the blow-off caps replaced as soon as possible.

b) On 7/8/10 at 9:10AM, one (1) out of two (2) of the fire suppression system discharge nozzle blow-off caps of the fire suppression system in the "Rio Cafe" cafeteria servery/food preparation area were found to be missing. In addition, two (2) out of two (2) of the fire suppression system discharge nozzle blow-off caps of the fire suppression system in the kitchen were found to be dust laden. As per concurrent interview with the facility's Director of Engineering, he will have the discharge nozzles cleaned and the blow-off caps replaced as soon as possible.

c) On 7/8/10 at 9:15AM, four (4) out of four (4) of the fire suppression system discharge nozzle blow-off caps of the fire suppression system in the "Rio Cafe" cafeteria kitchen/food preparation area were found to be missing. In addition, four (4) out of four (4) of the fire suppression system discharge nozzle blow-off caps of the fire suppression system in the kitchen were found to be heavily grease and dust laden. As per concurrent interview with the facility's Director of Engineering, he will have the discharge nozzles cleaned and the blow-off caps replaced as soon as possible.

42CFR 483.70(a)(1), NFPA 101-2000 Life Safety Code: 19.3.2.6, 9.2.3, NFPA 96-1998, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations: 8-2, NFPA 17A-1998 Standard for Wet Chemical Extinguishing Systems: 5-2
.

Based on observations and staff interview, the facility did not ensure that required separation distances between bulk oxygen systems and other structures and vehicles were maintained in accordance with applicable NFPA standards.

Findings:

a) On 7/7/10 at 11:08AM, a combustible modular building (e.g., the Infection Control Office) was found to be less than fifty (50) feet (e.g., thirty-eight (38) feet) from exposed piping of the bulk oxygen system.

b) On 7/7/10 at 11:11AM, combustible building (e.g., the road salt storage shed) was found to be less than fifty (50) feet (e.g., forty-two (42) feet) from exposed piping of the bulk oxygen system.

c) On 7/7/10 at 11:12AM, a vehicle (White Chevrolet Blazer) was found to be parked less than ten (10) feet (e.g., seven (7) feet) from the bulk oxygen system. As per concurrent interview with the facility's Director of Engineering, he would have the car moved as soon as possible.

d) On 7/13/10 at 8:20AM a pick-up truck was noted parked eight (8) feet from the bulk oxygen unit.

42CFR 483.70(a)(1), NFPA 99-1999: 4-3.1.1.2 (a) (10b), NFPA 50-1996: 2-2
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1) Based on observations and staff interview, the facility did not ensure that the arrangement of all means of egress in the Main Building was in accordance with NFPA 101-2000: 19.2.5.

Findings:

a) On the morning of 7/8/10, it was noted that a required means of exit access from the kitchen was through the Main Building "Rio Cafe" cafeteria food servery and seating area. Corridors shall provide access to exits without passing through any intervening rooms or spaces other than corridors or lobbies.

b) On 7/8/10 at 8:41AM, a folding metal security gate with a padlock was found in the means of egress from the Dietary Dry Goods Storage Room. As per concurrent interview with the facility'S Director of Engineering, he would have the padlock and gate removed as soon as possible.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.5.9, 19.2.5.2, 19.2.5.8


2) Based on observations, interviews, and record review, the facility did not ensure that fire hydrants on their property that they owned and were responsible for maintaining were maintained in accordance with the requirements of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Findings:

On 7/7/10 at 10:25AM bushes/vegetation were found to be only three (3) inches from one two and one-half (2 ?) inch hose outlet and directly against another two and one-half (2 ?) inch hose outlet of a fire hydrant on the hospital campus (vicinity of the main entrance drive). Access to hose connections on fire hydrants must be maintained. A clear space of at least thirty (30) inches shall be maintained around fire hydrant to ensure that they are accessible to fire service personnel. As per concurrent interview with the facility's Director of Environmental Services, he will have the bushes trimmed away from the fire hydrant so that firefighter access to it is not blocked.

42CFR 483.70(a)(1), NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems:4-2.2.4, 4-3.2, 4-3.4.3.1


3) Based on observations the facility did not ensure that the arrangement of all means of egress was in accordance with NFPA 101- 2000: 19.2.5.

Findings:

On 7/9/10 it was noted that travel distance to an exit access door from the OR suite involved two (2) room travel that was in excess of fifty (50) feet total distance. For example, the travel distance from the far point in OR #3 was eighty-five (85) feet and the distance from the far point in OR #6 was eighty (80) feet.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.5


4) Based on observations and record review (i.e., panelboard schedule) the Main Building was not provided with a Type 1 Essential Electrical System installed in accordance with NFPA 99.

Findings:

a) The wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System. For example:

- Emergency panel EC1B-ASU served both Equipment System circuits (e.g., condensate tank) and Emergency System circuits ( e.g., exit lights).

- 1st Floor emergency panel EM1B-1 served both Equipment System circuits (e.g., multiple exhaust fans) and Emergency System circuits (e.g., nurse call).

- 1st Floor emergency panel EM1A served Equipment System circuits (e.g., multiple heating units), Emergency System-Critical Branch circuits (e.g., nurse call) and Emergency System -Life Safety Code (i.e., Elevator lighting).

-1st Floor emergency panel EM1A served Equipment System circuits ( e.g., roof exhaust fan), Emergency System-Critical Branch circuits (e.g., Lab receptacles, Physical Therapy receptacles) and Emergency System -Life Safety Code (i.e., Medical Gas Alarm Panel).

b) The wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch. For example:

- Emergency panel LP-EM-3 (3S) served both Emergency System - Life Safety Branch circuits (e.g., medical gas alarm, corridor lighting) and Emergency System - Critical Branch circuits (e.g., nurse call system).

- Emergency panel EC1B-ASU served both Emergency System - Life Safety Branch circuits (e.g., exit lights) and Emergency System - Critical Branch circuits (e.g., lab receptacles).

- Emergency panel E1A served both Emergency System - Life Safety Branch circuits (e.g., exit light) and Emergency System - Critical Branch circuits (e.g., receptacles).

- Emergency panel EC1B served both Emergency System - Life Safety Branch circuits (e.g., Medical Gas Alarm Panel) and Emergency System - Critical Branch circuits (e.g., receptacles, nurse call).

- Emergency panel LP1LS served both Emergency System - Life Safety Branch circuits (e.g., exit lights, medical gas alarm panel) and Emergency System - Critical Branch circuits (e.g., Cysto warming unit).

- Emergency panel LCEOR7 served both Emergency System - Life Safety Branch circuits (e.g., medical gas alarm panel) and Emergency System - Critical Branch circuits (e.g., receptacles, sterilizer, laser).

10 NYCRR, 711.2(a)(26), NFPA 99 - 1999: Ch 3, NFPA 70: Article 517


5) Based on observations on the morning of 7/7/10 all ramps that served as portions of a means of egress were not in accordance with NFPA 101- 2010: 7.2.5 Ramps.

Findings:

A ramp that served as a portion of a means of egress from the loading dock area was not provided with handrails.

42CFR 483.70(a)(1), NFPA 101-2000: 19.2.2, 19.2.2.6, 7.2.5
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Based on observations, record review (i.e., panelboard schedule), and staff interview, the facility did not ensure that the Medical Office Building Endoscopy suite was not provided with a Type 1 Essential Electrical System installed in accordance with NFPA 99.

Findings:

a) Based on interviews with the Endoscopy Suite Nurse Manager on 7/7/10 at 1:53PM, it was determined that at least four (4) inpatients have customary access to the Endoscopy Unit at any one time and that invasive procedures are performed (e.g., diagnostic colonoscopies). NFPA 99, Standard for Health Care Facilities requires that a Type 1 Essential Electrical System be provided.

b) The wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System and the wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch. For example, on 7/7/10 at 1:12PM, it was noted that the Emergency Power Panel ELPLL in the lower-level of the Medical Office Building served items from the Emergency System - Life Safety Branch (i.e., Medical Gas Alarm Panel), Emergency System - Critical Branch (i.e., nurse call system and holding area receptacles) and the Equipment System (i.e., Boiler 32).

42CFR 483.70(a)(1), NFPA 99 - 1999 Standard for Health Care Facilities: 12-3.3.2, Ch 3, NFPA 70: Article 517

Based on observations, the facility failed to use Relocatable Power Taps (RPTs) in a safe manner. Reference is made to dangling RPTs that put excessive strain on the power cords that were plugged into the RPT.

Findings:

a) On 7/8/10 at 10:27AM a Relocatable Power Tap was noted dangling six (6) inches above the floor at a 2nd Floor Nursing Station. Two (2) computer related devices were plugged into the power tap.

b) On 7/8/10 at 11:05AM the RPT used to supply power to a Room Service Meal Ticket Printing Machine in the kitchen area was noted dangling down from the ceiling.

42CFR 483.70(a)(1), NFPA 101-2000: 19.5.1, NFPA 70
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Based on observations and interview the elevator serving the 4-story South Tower was not provided with Phase I smoke detector automatic recall.

Findings:

During a fire drill that was observed on 7/9/10 at 2:30PM, it was noted that the main elevator was not provided with automatic recall. Concurrent interview with the facility's Security Director revealed that Phase 1 automatic recall was not provided.

42CFR 483.70(a)(1), NFPA 101-2000: 19.5.3, 9.4.3.2
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