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1. During the survey, the following was observed:

A. Unsealed penetrations around flex conduit, and around a group of wiring, in the Fire Wall (2hr), by Cath Lab Waiting Basement.

B. Unsealed penetrations around conduit, in the Fire Wall (2hr), at Radiology.

C. Unsealed penetrations around flex conduit, in the Fire Wall (2hr), at Progressive Care Unit.

8.2.2.2* Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.



27382

The facility failed to maintain the two hour fire/smoke barriers per code. Findings include:

During the survey, the following was observed:
Fourth Floor
A. Two hour fire/smoke barrier by Labor and Delivery (4-F-S) at the fire doors - one unsealed conduit with red wires.
B. Fire doors in front of the Nurses' Station - the left leaf did not latch when tested.

Third Floor
The fire doors in front of the Nurses' Station the left leaf fire door did not latch when tested.

Fifth Floor
The fire doors in front of room 577 - the right leaf did not latch when tested.

2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.

2000 NFPA 101, 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following. (a) * Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1. (b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

The facility failed to provide corridor walls that would provide at least a 30 minute fire resistance rating. Findings include:

During the survey, unsealed penetrations were observed, at the deck, of the corridor wall, by Patient Room 374.

NFPA 101, 19.3.6.1 Corridors in unsprinklered smoke compartments shall be separated from all other areas by partitions having a fire resistance rating of at least 30 minutes.

The facility failed to maintain the corridor openings per code. Findings include:

During the survey, on the third floor at the 'old' Heart Health now Storage Room the corridor door was blocked from being able to close by two carts.

2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following was observed:

1. Unsealed penetrations around a sprinkler line, in the Smoke Barrier, by Cardiouascular Ultrasound Basement.
2. Unsealed penetrations at the end of a sleeve, in the Smoke Barrier, by Patient Room 177.
3. Unsealed penetrations around conduit, and at the end of a sleeve, in the Smoke Barrier, by the Monitor Room Third Floor West.

NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to perform sensitivity testing of the smoke detectors. Findings include:

Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following was observed:

A) Missing ceiling tiles in the Nitrous Oxide Room.

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.

B) Escutcheon plate missing on a sprinkler at the main entrance of the facility.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.



27382

The facility failed to maintain the sprinkler system per code. Findings include:

C) During the survey, the following was observed:
1. Second Floor - Break Down Box Room in the O.R. - the attic access in the closet is falling out of the ceiling.
2. Third Floor - Old Heart Health now Storage - was missing ceiling tile.

1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.

The facility failed to maintain the smoke dampers per code. Findings include:

During the survey, the following was observed:
1. Fifth Floor - the smoke damper at the smoke doors in front of the Nurses' Station did not close when the fire alarm was tested.
2. Fourth Floor - the smoke damper for the fire/smoke barrier at the fire doors (4-F-S-70) at room 460 did not close when the fire alarm was tested.
3. Third Floor - the fire/smoke barrier at the Pharmacy/the entrance to C.C.U. (A-3-18) access panel could not be found.
4. Second Floor - the fire/smoke barrier at the fire doors (2-F-31) had a fire damper, but no smoke damper.

1999 NFPA 90A, 3-3.5.1 Smoke dampers shall be installed at or adjacent to the point where air ducts pass through required smoke barriers, but in no case shall a smoke damper be installed more than 2 ft (0.6 m) from the barrier or after the first air duct inlet or outlet, whichever is closer to the smoke barrier.
1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

The facility failed to maintain the dietary hood. Findings include:

A) During the survey, the filters in the dietary hood in the Short Line Grill, were observed to be damaged, causing the filters not to be held tight and firmly in place.


NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.


B) During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank. For the Main Kitchen, and the Short Line Grill, which is two separate extinguishing sytems.


NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

The facility failed to provide proper storage of oxygen cylinders. Findings include:

A) During the survey, appropriate signage was not provided, no smoking sign was displaced in room, or on the door as you entered.

CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.

The facility failed to maintain the medical gas systems per code. Findings include:

During the survey, the following was observed:
1. Fourth Floor - the medical gas alarm panel at the Nurses' Station (MGA 4-01), the oxygen did not give an audible alarm when tested.

2. According to the documentation provided by the facility from the 02/22/2010 medical gas system inspection report, the medical gas system did not comply with NFPA 99.

1999 NFPA 99, 4-3.1.2.2 Gas Warning Systems. (a) * General. 1. All local, master, and area alarm panels used for medical gas systems shall provide the following: a. Separate visual indicators for each condition monitored, b. Cancelable audible indication of an alarm condition. The audible indicator shall produce a minimum of 80 dBA measured at 3 ft (1 m). A second indicated condition occurring while the alarm is silenced shall reinitiate the audible signal, c. A means to visually indicate a lamp or LED failure 2. Local, master, and area alarms shall indicate visually and audibly if, a. The monitored condition occurs b The wiring to the sensor or switch is disconnected.
1999 NFPA 99 Piped medical gas systems shall meet all requirements of NFPA 99.

The facility failed to maintain a smoke barrier per code. Findings include:

During the survey, on the Sixth Floor at the smoke doors on the left side in front of the Nurses' Station (6 - F - S - 23) the smoke barrier had an unsealed conduit with several blue wires.

2000 NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose.

The facility failed to maintain the Line Isolation Monitors (L.I.M.) per code. Findings include:

During the survey, the following L.I.M. in the O.R. on the Second Floor were observed not to alarm when tested:
1. L.I.M. marked "Aramark 0519"
2. L.I.M. marked "Aramark 0510"

1999 NFPA 99, 3-3.2.2.3 Line Isolation Monitor. (a) * In addition to the usual control and protective devices, each isolated power system shall be provided with an approved continually operating line isolation monitor that indicates possible leakage or fault currents from either isolated conductor to ground. (b) The monitor shall be designed such that a green signal lamp, conspicuously visible to persons in the anesthetizing location, remains lighted when the system is adequately isolated from ground; and an adjacent red signal lamp and an audible warning signal (remote if desired) shall be energized when the total hazard current (consisting of possible resistive and capacitive leakage currents) from either isolated conductor to ground reaches a threshold value of 5.0 mA under normal line voltage conditions. The line isolation monitor shall not alarm for a fault hazard current of less than 3.7 mA. (c) The line isolation monitor shall have sufficient internal impedance such that, when properly connected to the isolated system, the maximum internal current that will flow through the line isolation monitor, when any point of the isolated system is grounded, shall be 1 mA.
1999 NFPA 99, 3-3.3.4.2 Line Isolation Monitor Tests. The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following: (a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated. (b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. (c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

The facility failed to maintain the generator per code. Findings include:

During the survey, the facility failed to provide documentation of weekly visual inspections on all three of the generators.

1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

A) During the survey, two junctions boxes were observed to be missing the covers, in the Housekeeping Storage Room.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.



27382

B) The facility failed to maintain the electrical system per code. Findings include:

During the survey, the following was observed:
1. Fourth Floor the fire/smoke barrier at Labor and Delivery had two junction boxes without cover plates.
2. Fourth Floor - Manager's Office had a refrigerator plugged into a surge protector.
3. Fourth Floor - Call Room 1 in O.B. - had a homemade extension cord with an an electrical four gang outlet on one end with an extension cord and a surge protector were plugged into it.
4. Second Floor - O.R. Scheduling had an extension cord plugged into a surge protector.
5. Second Floor - O.R. Breakroom had a homemade extension cord with an an electrical outlet on one end; a microwave was plugged into it and it was laying on the microwave.
6. Second Floor - Medical Records had several surge protectors plugged into other surge protectors.
7. Seventh Floor - Radio Room had a microwave plugged into a surge protector, that surge protector was plugged into another surge protector, that also had a refrigerator plugged into it.
8. Sixth Floor - Case Management Office had a refrigerator plugged into one surge protector and a microwave plugged into another surge protector.
9. Third Floor - Maintenance Break Room had a homemade extension cord with an an electrical outlet on one end; a refrigerator was plugged into it.
10. Third Floor - Respiratory Therapy Break Room had a microwave plugged into a surge protector.
11. Third Floor - Utilization Review - had a microwave and a refrigerator plugged into a surge protector.

1999 NFPA 70, 370-28 Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d). (c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.
1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle.

1999 NFPA 70, 400-7 Uses Permitted (a) Uses. Flexible cords and cables shall be used only for the following: 1. Pendants 2. Wiring of fixtures 3. Connection of portable lamps, portable and mobile signs, or appliances 4. Elevator cables 5. Wiring of cranes and hoists 6. Connection of stationary equipment to facilitate their frequent interchange 7.Prevention of the transmission of noise or vibration 8. Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection 9. Data processing cables as permitted by Section 645-5 10. Connection of moving parts 11. Temporary wiring as permitted in Sections 305-4(b) and 305-4(c) (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.
2000 NFPA 101, 9.1.2 Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

1. During the survey, the following was observed:

A. Unsealed penetrations around flex conduit, and around a group of wiring, in the Fire Wall (2hr), by Cath Lab Waiting Basement.

B. Unsealed penetrations around conduit, in the Fire Wall (2hr), at Radiology.

C. Unsealed penetrations around flex conduit, in the Fire Wall (2hr), at Progressive Care Unit.

8.2.2.2* Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.



27382

The facility failed to maintain the two hour fire/smoke barriers per code. Findings include:

During the survey, the following was observed:
Fourth Floor
A. Two hour fire/smoke barrier by Labor and Delivery (4-F-S) at the fire doors - one unsealed conduit with red wires.
B. Fire doors in front of the Nurses' Station - the left leaf did not latch when tested.

Third Floor
The fire doors in front of the Nurses' Station the left leaf fire door did not latch when tested.

Fifth Floor
The fire doors in front of room 577 - the right leaf did not latch when tested.

2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met: a. The material shall be capable of maintaining the fire resistance of the fire barrier. b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the fire barrier. b. It shall be made by an approved device that is designed for the specific purpose.

2000 NFPA 101, 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following. (a) * Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1. (b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

The facility failed to provide corridor walls that would provide at least a 30 minute fire resistance rating. Findings include:

During the survey, unsealed penetrations were observed, at the deck, of the corridor wall, by Patient Room 374.

NFPA 101, 19.3.6.1 Corridors in unsprinklered smoke compartments shall be separated from all other areas by partitions having a fire resistance rating of at least 30 minutes.

The facility failed to maintain the corridor openings per code. Findings include:

During the survey, on the third floor at the 'old' Heart Health now Storage Room the corridor door was blocked from being able to close by two carts.

2007 CMS - 2786R There is no impediment to the closing of the corridor doors.

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following was observed:

1. Unsealed penetrations around a sprinkler line, in the Smoke Barrier, by Cardiouascular Ultrasound Basement.
2. Unsealed penetrations at the end of a sleeve, in the Smoke Barrier, by Patient Room 177.
3. Unsealed penetrations around conduit, and at the end of a sleeve, in the Smoke Barrier, by the Monitor Room Third Floor West.

NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to perform sensitivity testing of the smoke detectors. Findings include:

Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following was observed:

A) Missing ceiling tiles in the Nitrous Oxide Room.

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.

B) Escutcheon plate missing on a sprinkler at the main entrance of the facility.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.



27382

The facility failed to maintain the sprinkler system per code. Findings include:

C) During the survey, the following was observed:
1. Second Floor - Break Down Box Room in the O.R. - the attic access in the closet is falling out of the ceiling.
2. Third Floor - Old Heart Health now Storage - was missing ceiling tile.

1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.

The facility failed to maintain the smoke dampers per code. Findings include:

During the survey, the following was observed:
1. Fifth Floor - the smoke damper at the smoke doors in front of the Nurses' Station did not close when the fire alarm was tested.
2. Fourth Floor - the smoke damper for the fire/smoke barrier at the fire doors (4-F-S-70) at room 460 did not close when the fire alarm was tested.
3. Third Floor - the fire/smoke barrier at the Pharmacy/the entrance to C.C.U. (A-3-18) access panel could not be found.
4. Second Floor - the fire/smoke barrier at the fire doors (2-F-31) had a fire damper, but no smoke damper.

1999 NFPA 90A, 3-3.5.1 Smoke dampers shall be installed at or adjacent to the point where air ducts pass through required smoke barriers, but in no case shall a smoke damper be installed more than 2 ft (0.6 m) from the barrier or after the first air duct inlet or outlet, whichever is closer to the smoke barrier.
1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

The facility failed to maintain the dietary hood. Findings include:

A) During the survey, the filters in the dietary hood in the Short Line Grill, were observed to be damaged, causing the filters not to be held tight and firmly in place.


NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.


B) During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. This side of the inspection card was blank. For the Main Kitchen, and the Short Line Grill, which is two separate extinguishing sytems.


NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer 's listed installation and maintenance manual or owner 's manual. As a minimum, this "quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

The facility failed to provide proper storage of oxygen cylinders. Findings include:

A) During the survey, appropriate signage was not provided, no smoking sign was displaced in room, or on the door as you entered.

CGA G-4, 4.1.10, and 1999 NFPA 99, 4-3.5.2.2(b)2 and 4-5.5.2.2(b)2 Full and empty cylinders shall be stored separately, with appropriate signage.

The facility failed to maintain the medical gas systems per code. Findings include:

During the survey, the following was observed:
1. Fourth Floor - the medical gas alarm panel at the Nurses' Station (MGA 4-01), the oxygen did not give an audible alarm when tested.

2. According to the documentation provided by the facility from the 02/22/2010 medical gas system inspection report, the medical gas system did not comply with NFPA 99.

1999 NFPA 99, 4-3.1.2.2 Gas Warning Systems. (a) * General. 1. All local, master, and area alarm panels used for medical gas systems shall provide the following: a. Separate visual indicators for each condition monitored, b. Cancelable audible indication of an alarm condition. The audible indicator shall produce a minimum of 80 dBA measured at 3 ft (1 m). A second indicated condition occurring while the alarm is silenced shall reinitiate the audible signal, c. A means to visually indicate a lamp or LED failure 2. Local, master, and area alarms shall indicate visually and audibly if, a. The monitored condition occurs b The wiring to the sensor or switch is disconnected.
1999 NFPA 99 Piped medical gas systems shall meet all requirements of NFPA 99.

The facility failed to maintain a smoke barrier per code. Findings include:

During the survey, on the Sixth Floor at the smoke doors on the left side in front of the Nurses' Station (6 - F - S - 23) the smoke barrier had an unsealed conduit with several blue wires.

2000 NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b. It shall be protected by an approved device that is designed for the specific purpose.

The facility failed to maintain the Line Isolation Monitors (L.I.M.) per code. Findings include:

During the survey, the following L.I.M. in the O.R. on the Second Floor were observed not to alarm when tested:
1. L.I.M. marked "Aramark 0519"
2. L.I.M. marked "Aramark 0510"

1999 NFPA 99, 3-3.2.2.3 Line Isolation Monitor. (a) * In addition to the usual control and protective devices, each isolated power system shall be provided with an approved continually operating line isolation monitor that indicates possible leakage or fault currents from either isolated conductor to ground. (b) The monitor shall be designed such that a green signal lamp, conspicuously visible to persons in the anesthetizing location, remains lighted when the system is adequately isolated from ground; and an adjacent red signal lamp and an audible warning signal (remote if desired) shall be energized when the total hazard current (consisting of possible resistive and capacitive leakage currents) from either isolated conductor to ground reaches a threshold value of 5.0 mA under normal line voltage conditions. The line isolation monitor shall not alarm for a fault hazard current of less than 3.7 mA. (c) The line isolation monitor shall have sufficient internal impedance such that, when properly connected to the isolated system, the maximum internal current that will flow through the line isolation monitor, when any point of the isolated system is grounded, shall be 1 mA.
1999 NFPA 99, 3-3.3.4.2 Line Isolation Monitor Tests. The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following: (a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated. (b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. (c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

The facility failed to maintain the generator per code. Findings include:

During the survey, the facility failed to provide documentation of weekly visual inspections on all three of the generators.

1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

A) During the survey, two junctions boxes were observed to be missing the covers, in the Housekeeping Storage Room.

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.



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B) The facility failed to maintain the electrical system per code. Findings include:

During the survey, the following was observed:
1. Fourth Floor the fire/smoke barrier at Labor and Delivery had two junction boxes without cover plates.
2. Fourth Floor - Manager's Office had a refrigerator plugged into a surge protector.
3. Fourth Floor - Call Room 1 in O.B. - had a homemade extension cord with an an electrical four gang outlet on one end with an extension cord and a surge protector were plugged into it.
4. Second Floor - O.R. Scheduling had an extension cord plugged into a surge protector.
5. Second Floor - O.R. Breakroom had a homemade extension cord with an an electrical outlet on one end; a microwave was plugged into it and it was laying on the microwave.
6. Second Floor - Medical Records had several surge protectors plugged into other surge protectors.
7. Seventh Floor - Radio Room had a microwave plugged into a surge protector, that surge protector was plugged into another surge protector, that also had a refrigerator plugged into it.
8. Sixth Floor - Case Management Office had a refrigerator plugged into one surge protector and a microwave plugged into another surge protector.
9. Third Floor - Maintenance Break Room had a homemade extension cord with an an electrical outlet on one end; a refrigerator was plugged into it.
10. Third Floor - Respiratory Therapy Break Room had a microwave plugged into a surge protector.
11. Third Floor - Utilization Review - had a microwave and a refrigerator plugged into a surge protector.

1999 NFPA 70, 370-28 Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d). (c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.
1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle.

1999 NFPA 70, 400-7 Uses Permitted (a) Uses. Flexible cords and cables shall be used only for the following: 1. Pendants 2. Wiring of fixtures 3. Connection of portable lamps, portable and mobile signs, or appliances 4. Elevator cables 5. Wiring of cranes and hoists 6. Connection of stationary equipment to facilitate their frequent interchange 7.Prevention of the transmission of noise or vibration 8. Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection 9. Data processing cables as permitted by Section 645-5 10. Connection of moving parts 11. Temporary wiring as permitted in Sections 305-4(b) and 305-4(c) (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.
2000 NFPA 101, 9.1.2 Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.