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The facility did not ensure that hazardous areas were separated by smoke resisting partitions and self-closing doors as required by section # 19.3.2.1 of the " Life Safety Code "

1. On 05/05/14 at 10:15 AM the surveyor, while accompanied by the Director of Engineering and the Director of Safety & Security observed that the 2 (two) doors from the corridor to the Anesthesia Work Room on the 1st floor of the Pomeroy Building (Operating Room Nursing Unit) were not provided with self-closing devices, as required by section # 19.3.2.1 of the " Life Safety Code "; door hardware has been removed from hazardous area;

2. On 05/05/14 at 10:50 AM the surveyor, while accompanied by the Director of Engineering and the Director of Safety & Security observed that the door from the corridor to the (old) Assistant Managers Office (Room # 1639) on the 1st floor of the Reed Building (Operating Room Nursing Unit) was not provided with a self-closing device, as required by section # 19.3.2.1 of the " Life Safety Code "; door hardware has been removed from hazardous area;

3. On 05/05/14 at 1:30 PM the surveyor, while accompanied by the Director of Engineering observed that the door from the corridor to the Storage Room (Room # 3503) on the 3rd floor adjacent to the Special Care Nursery was not provided with a self-closing device, as required by section # 19.3.2.1 of the " Life Safety Code "; door hardware has been removed from hazardous area;

The facility did not ensure that laboratories employing quantities of flammable, combustible, or hazardous materials that are considered a severe hazard are protected in accordance with NFPA 99, " Standard for Health Care Facilities " , and NFPA 99, " Heath Care Facility ' s " . Section # ' s 19.3.2.2, 19.3.2.1 & 8.4.4

1. On 05/06/14 at 1:30 PM the surveyor while accompanied by the Director of Engineering and the Director of Safety & Security observed that the inside, (flammable & combustible) storage closet located just inside the Pharmacy entry door in the Old Building-West Wing-3rd floor, was not provided/constructed with interior walls, ceilings and intermediate floors that had a one-hour, fire resistance rating, as required by section # 4-4.2.1 and Table # 4-4.2.1 of NFPA 30, "Flammable & Combustible Liquids Code" ; i.e. the joints where the walls meet the ceiling and the conduits that run through the closet are not sealed with materials that have a one-hour fire rating;

2. On 05/06/14 at 1:30 PM the surveyor while accompanied by the Director of Engineering and the Director of Safety & Security observed that the inside, (flammable & combustible) storage closet located just inside the Pharmacy entry door in the Old Building-West Wing-3rd floor, was not provided/constructed with containment or drainage for the largest credible spill, as required by section # 4-4.2.7 of NFPA 30, "Flammable & Combustible Liquids Code" ; i.e.closet not provided with containment or drainage.

The facility did not ensure that solid linen or trash collection receptacles do not exceed 32 gal in capacity and mobile soiled linen or trash collection receptacles with capacities greater than 32 gal are located in a room protected as a hazardous area when not attended as required by the referenced " Life Safety Code "

On 05/05/14 at 10:55 AM and at different dates & times throughout the survey, the surveyor while accompanied by the Director of Engineering and the Director of Safety & Security observed that the mobil, soiled linen or trash collection receptacles with capacities greater than 32 gal were not located in a room protected as a hazardous area when not attended as required by the referenced Life Safety Code; i.e. open-top, soiled linen carts, trash cans with lids observed throughout the exit-access corridors.

The facility did not ensure that piped in medical gas systems are in compliance with sections 4.1, 4.1.1 NFPA 99, " Health Care Facility ' s " .

On 05/07/14 at 11:00 AM , the surveyors were not provided with documentation from the Director of Engineering or the Director of Safety & Security to indicate that the concerns, deficiencies and violations listed upon the Environmental Technology Associates inspection/testing report of 09/18/13 have been properly addressed, as required by NFPA 99, " Health Care Facility ' s " ; i.e. 4 (four) pages of various conditions that require attention-quotes for repair obtained-no definitive date repairs will be conducted

1. The facility did not ensure that Emergency and Standby Power Systems were being inspected and maintained as required in NFPA 110, " Standard for Emergency and Standby Power Systems " .

On 05/07/14 at 11:30 AM , the surveyors were not provided with documentation from the Director of Engineering or the Director of Safety & Security to indicate that the concerns, deficiencies and violations listed upon the Atlantic Detroit Diesel inspection/testing reports from 03/14 & 08/22/13 have been properly addressed, as required by NFPA 99, " Health Care Facility ' s " and NFPA 110, " Standard for Emergency and Standby Power Systems " ;i.e. contractor has identified cooling system (radiator) issues with emergency generators- quotes for repair obtained-no definitive date repairs will be conducted

2. The facility did not ensure that the proper protection of patients included the prompt and effective response of health care personnel, as required by section # 19.7.2.1 of the " Life Safety Code "

On 05/06/14 at 11:00 AM the surveyor, while accompanied by the Director of Engineering learned during an interview with staff members from the Labor & Delivery Nursing Unit use a piece of specialized equipment (vest) to evacuate infants from the nursing unit in the event of an emergency. The surveyor, while accompanied by the Director of Engineering then observed that it took staff members from the Labor & Delivery Nursing Unit an, long, period of time (approximately 15 minutes) to find and locate the piece of specialized equipment (vest) from wherever it was being stored (eventually located in a closet outside of the nursery) at the Nursing Unit; i.e. proper protection of patients requires the prompt and effective response of health care personnel and was not observed by surveyor

The facility did not ensure that hazardous areas were separated by smoke resisting partitions and self-closing doors as required by section # 19.3.2.1 of the " Life Safety Code "

1. On 05/05/14 at 10:15 AM the surveyor, while accompanied by the Director of Engineering and the Director of Safety & Security observed that the 2 (two) doors from the corridor to the Anesthesia Work Room on the 1st floor of the Pomeroy Building (Operating Room Nursing Unit) were not provided with self-closing devices, as required by section # 19.3.2.1 of the " Life Safety Code "; door hardware has been removed from hazardous area;

2. On 05/05/14 at 10:50 AM the surveyor, while accompanied by the Director of Engineering and the Director of Safety & Security observed that the door from the corridor to the (old) Assistant Managers Office (Room # 1639) on the 1st floor of the Reed Building (Operating Room Nursing Unit) was not provided with a self-closing device, as required by section # 19.3.2.1 of the " Life Safety Code "; door hardware has been removed from hazardous area;

3. On 05/05/14 at 1:30 PM the surveyor, while accompanied by the Director of Engineering observed that the door from the corridor to the Storage Room (Room # 3503) on the 3rd floor adjacent to the Special Care Nursery was not provided with a self-closing device, as required by section # 19.3.2.1 of the " Life Safety Code "; door hardware has been removed from hazardous area;

The facility did not ensure that laboratories employing quantities of flammable, combustible, or hazardous materials that are considered a severe hazard are protected in accordance with NFPA 99, " Standard for Health Care Facilities " , and NFPA 99, " Heath Care Facility ' s " . Section # ' s 19.3.2.2, 19.3.2.1 & 8.4.4

1. On 05/06/14 at 1:30 PM the surveyor while accompanied by the Director of Engineering and the Director of Safety & Security observed that the inside, (flammable & combustible) storage closet located just inside the Pharmacy entry door in the Old Building-West Wing-3rd floor, was not provided/constructed with interior walls, ceilings and intermediate floors that had a one-hour, fire resistance rating, as required by section # 4-4.2.1 and Table # 4-4.2.1 of NFPA 30, "Flammable & Combustible Liquids Code" ; i.e. the joints where the walls meet the ceiling and the conduits that run through the closet are not sealed with materials that have a one-hour fire rating;

2. On 05/06/14 at 1:30 PM the surveyor while accompanied by the Director of Engineering and the Director of Safety & Security observed that the inside, (flammable & combustible) storage closet located just inside the Pharmacy entry door in the Old Building-West Wing-3rd floor, was not provided/constructed with containment or drainage for the largest credible spill, as required by section # 4-4.2.7 of NFPA 30, "Flammable & Combustible Liquids Code" ; i.e.closet not provided with containment or drainage.

The facility did not ensure that solid linen or trash collection receptacles do not exceed 32 gal in capacity and mobile soiled linen or trash collection receptacles with capacities greater than 32 gal are located in a room protected as a hazardous area when not attended as required by the referenced " Life Safety Code "

On 05/05/14 at 10:55 AM and at different dates & times throughout the survey, the surveyor while accompanied by the Director of Engineering and the Director of Safety & Security observed that the mobil, soiled linen or trash collection receptacles with capacities greater than 32 gal were not located in a room protected as a hazardous area when not attended as required by the referenced Life Safety Code; i.e. open-top, soiled linen carts, trash cans with lids observed throughout the exit-access corridors.

The facility did not ensure that piped in medical gas systems are in compliance with sections 4.1, 4.1.1 NFPA 99, " Health Care Facility ' s " .

On 05/07/14 at 11:00 AM , the surveyors were not provided with documentation from the Director of Engineering or the Director of Safety & Security to indicate that the concerns, deficiencies and violations listed upon the Environmental Technology Associates inspection/testing report of 09/18/13 have been properly addressed, as required by NFPA 99, " Health Care Facility ' s " ; i.e. 4 (four) pages of various conditions that require attention-quotes for repair obtained-no definitive date repairs will be conducted

1. The facility did not ensure that Emergency and Standby Power Systems were being inspected and maintained as required in NFPA 110, " Standard for Emergency and Standby Power Systems " .

On 05/07/14 at 11:30 AM , the surveyors were not provided with documentation from the Director of Engineering or the Director of Safety & Security to indicate that the concerns, deficiencies and violations listed upon the Atlantic Detroit Diesel inspection/testing reports from 03/14 & 08/22/13 have been properly addressed, as required by NFPA 99, " Health Care Facility ' s " and NFPA 110, " Standard for Emergency and Standby Power Systems " ;i.e. contractor has identified cooling system (radiator) issues with emergency generators- quotes for repair obtained-no definitive date repairs will be conducted

2. The facility did not ensure that the proper protection of patients included the prompt and effective response of health care personnel, as required by section # 19.7.2.1 of the " Life Safety Code "

On 05/06/14 at 11:00 AM the surveyor, while accompanied by the Director of Engineering learned during an interview with staff members from the Labor & Delivery Nursing Unit use a piece of specialized equipment (vest) to evacuate infants from the nursing unit in the event of an emergency. The surveyor, while accompanied by the Director of Engineering then observed that it took staff members from the Labor & Delivery Nursing Unit an, long, period of time (approximately 15 minutes) to find and locate the piece of specialized equipment (vest) from wherever it was being stored (eventually located in a closet outside of the nursery) at the Nursing Unit; i.e. proper protection of patients requires the prompt and effective response of health care personnel and was not observed by surveyor