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Based on observation and staff interview, the facility failed to separate use areas from corridors with smoke resisting partitions or with barrier ratings specified by facility floor plans by not maintaining barriers free of penetrations. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
Observations on 12/1/10, from 8:27 am to 8:29 am revealed:
1. Above ceiling at Room 3261 revealed a one foot square hole around ductwork in the corridor wall.
2. Above ceiling from Room 3260 to 3250 the corridor wall failed to extend to the floor above. From the Conference Room to the Lactation Consultant Room, the corridor wall failed to extend to the floor above.
The observations were confirmed by Engineering B on the same date and time.


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Observations on 11/30/10, from 11:10 AM to 12-1-10 at 4:10 PM revealed:
3. A penetration in the ¿¿2-hour wall above the ceiling in the " mammo " area. This hole was rather large and a good portion of the wall was missing (approximately 3 - 4 feet of brick was gone).
4. A penetration in the ¿¿2-hour wall above the ceiling in the ambulatory care center area which is the other side of the " mammo " wall.
5. A penetration, approximately 2 inches in diameter in the 2¿¿-hour wall above the ceiling in the Radiology bathroom area (near supervisor ' s office). There were also pipes running through the ceiling that were in need of fire rated gaskets or fire caulking material to ensure no vertical smoke or fire spread.
6. A penetration in the ¿¿2-hour wall above the ceiling in the Radiology west side entry / exit vestibule area. This hole was approximately 1 inch by 3 inches in size.
7. A penetration in the 2¿¿-hour fire rated wall above the ceiling in the dock area. There was a fairly large hole noted behind several electrical conduits and also a small hole near there. These penetrations were above a set of 90 minute fire rated doors. There were penetrations on both sides of this wall above the doors. Some of the penetrations were stuffed with fiberglass insulation but not with a rated material. Along with the conduit holes, other penetrations were along a drywall seam where communication wires were going through the wall.
8. There were penetrations in the 1¿¿-hour rated smoke wall above the ceiling in the " Endo " (Endoscopy) area. There was an 8-inch by 8-inch hole noted around some electrical conduit. There was also a hole around a fire sprinkler pipe labeled " Fire Main " - this was a 4-inch pipe that went through a 6-inch hole. These penetrations were (again) near the " Endo " area, above the Dr. portraits.
9. A penetration in the 1¿¿-hour fire wall above the ceiling in the Radiology lounge area. This was a smaller hole (less than 2-inches diameter) around some communication wires.
10. A penetration in the 1¿¿-hour smoke wall above the ceiling in the Radiology entrance area. This area is adjacent to the vending machine area and the deficiency was noted above a set of 45-minute rated doors in the corridor. There were holes around electrical conduit, a " tube station " pipe had a hole around it (approximately 1 to 2-inches larger than needed and there were communication wires with holes around them that needed to be sealed with fire caulk or another approved material.
11. A penetration in the ¿¿1-hour wall above the ceiling in the in the corridor of compartment 1J (per blue print) on the ground floor. This penetration was not properly sealed. It had been sealed with non-rated polyurethane expanding foam. Another larger penetration (Approximately 1-foot by 2-feet) nearby had also been sealed with foam insulation panels instead of drywall.
12. A penetration in the 4¿¿-hour fire rated wall above the ceiling in the Kearney Imaging Center area. This was above a set of 3-hour rated doors in the corridor and the penetration was around electrical conduit, approximately 2 - 3-inches in diameter.
13. A penetration in the 2¿¿-hour rated smoke wall above the ceiling in the Doctor Office area (across from outpatient room 4, off of the corridor) on the ground floor. There were holes through this brick wall where it had been penetrated to run electrical conduits through. Each hole was approximately 1-inch larger than it needed to be.
14. A penetration in the ¿¿2-hour rated smoke wall above the ceiling in the Operating Room entrance area (near stairs, in corridor). There were large chunks of the top layer of drywall missing (there were two layers of 5/8 " drywall) in one area there was a 2 by 2-foot section missing and also an 8 by 8-inch section of the top layer of drywall missing. The missing layers could allow flames and smoke to penetrate this barrier sooner than expected.
15. There were penetrations in the 2¿¿-hour rated wall above the ceiling in the Care management meeting room and offices area. There was a 2-inch by 3-inch hole around some flex conduit and also several smaller holes above the ceiling of office C.
16. There were penetrations in the 2¿¿-hour wall above the ceiling and fire rated doors in between the hospital and Medical Office Building (corridor) on the ground floor. These were smaller holes around electrical conduit and communication wires.
17. There were penetrations in the 1¿¿-hour wall above the ceiling in the West tower area 1A (per blue print) area " Emporium " fire wall. There were holes around sprinkler pipes and electrical conduit. There were also miscellaneous holes around communication wires and also ventilation ducts.
18. A penetration in the ¿¿1-hour wall above the ceiling in the West tower office area (near office 9) area. There was a 3-inch by 5-inch rectangular hole cut out. This was pointed out to be a problem because smoke and fire could easily pass through this opening.
19. A penetration in the ¿¿1-hour wall above the ceiling in the West Tower area (near stairs). Near the stairwell there were holes around pipes (down in the soffit). Each pipe had a hole approximately 1-inch greater than it needed to be. These are in need of rated gaskets or fire caulk to ensure no spreading of smoke or fire.
20. The observations were confirmed by Engineering C and D on the same dates and time frame. Engineering C and D both documented the deficiencies on paper and with photographs to ensure prompt and proper repair.
21. Observation on the 2nd Floor above ceiling revealed a hole in the pre-cast concrete ceiling above the Stair Tower 2B15E Door.
The observations were confirmed by Engineering C and D on the same dates and time frame. Engineering C and D both documented the deficiencies on paper and with photographs to ensure prompt and proper repair.

Based on observation and staff interview, the facility failed to enclose an elevator shaft and an atrium with one hour fire resistance construction by not maintaining barriers free of penetrations. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 80 and the census was 20.

Findings are:
Observations on 12/1/10, from 1:49 pm to 2:55 pm revealed:
1. Above ceiling at the Atrium Fire Doors near the Revenue Realization Center had a hole around cables in the barrier wall.
2. Above ceiling at the Atrium Fire Doors outside of the Adult Unit revealed penetrations in the barrier wall.
3. Above ceiling on the Lower Level at the Freight Elevator revealed a hole around copper pipe in the shaft wall.
The observations were confirmed by Safety Officer E on the same date and time.

Based on observation and staff interview, the facility failed to enclose an elevator shaft and stair tower walls with one hour fire resistance construction. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
1. Observations on 11/30/10, from 11:55 am to 4:12 pm revealed:

2. Observation on the Lower Level above ceiling revealed a penetration in the elevator shaft of Elevator 6.

Observations on Level A revealed:
3. Above ceiling in the Clinical Engineering Break Room revealed a one foot square hole for conduits and holes around conduits above the stair tower door.
4. Inside the ER Entrance was a two story stairwell. At the bottom of the stairs were a set of double doors that had a fire resistance rating of 20 minutes with wire glass. The doors did not have latching hardware. The facility failed to provide doors with latching hardware and a fire resistance rating of one hour.

5. Observation on the 2nd Floor above ceiling revealed a hole in the pre-cast concrete ceiling above the Stair Tower 2B15E Door.
The observations were confirmed by Engineering B on the same date and time.

Actual NFPA Standard: NFPA 101 Chapter 7.1.3.2 Exits.
Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following.
(a) * The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.

Based on observation and interview, the facility failed to assure barrier doors were equipped with hold-open devices that actuated by a local smoke detector. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
On November 30, 2010, between 10:30 A.M. and 5:30 P.M. observation revealed that the fire doors that were used as smoke separation doors, between Radiology and Staff Elevators do not have smoke detection located within five feet of the doors. Observations were confirmed by Project Manager F.

Based on observation and staff interview, the facility failed to accurately mark the means of egress when not readily apparent. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
Observations on 11/30/10, at 2:07 pm on Level A revealed an exit sign marked the A600 Stairs as an exit. The A600 Stair Door was marked " not an exit " because the stairs did not exit to the outside. The facility failed to remove the exit sign marking the A600 Stairs as an exit.
The observations were confirmed by Engineering B on the same date and time.

Based on observation and staff interview, the facility failed to provide smoke barriers with construction of at least one half hour fire resistance rating by not maintaining barriers free of penetrations. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
1. Observations on 11/30/10, from 11:32 am to 12/1/10, 3:44 pm revealed:

Observations on the Lower Level revealed:
2. Holes around electrical conduits in the barrier above the BB01J Double Doors.
3. Holes around communication wires in the barrier above the BC05C Double Doors.

4. Observation on the 2nd Floor revealed a hole around a wire in the barrier above the 2C024 Double Doors.
The observations were confirmed by Engineering B on the same date and time.

Based on observation and staff interview, the facility failed to provide smoke barriers with construction of at least one half hour fire resistance rating by not maintaining barriers free of penetrations. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 80 and the census was 20.

Findings are:
Observations on 12/1/10, from 2:32 pm to 2:59 pm revealed:
1. Above ceiling in the Fan Coil Attic Space of the Lower Level Youth Unit revealed a 2 foot square hole cut in the smoke barrier wall.
2. Above ceiling at the corridor double doors leading into the mechanical room outside of the Gym revealed holes around cables in the barrier wall.
The observations were confirmed by Safety Officer E on the same date and time.

Based on observation and interview, the facility failed to maintain doors in smoke barriers that resist the passage of smoke. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
On November 30, 2010, between 10:30 A.M. and 5:30 P.M. observation revealed that the smoke separation doors, between Radiology and Staff Elevators do not properly close to create a barrier that would resist the passage of smoke. Observations were confirmed by Project Manager F.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
Observations on 11/30/10, from 1:39 pm to 3:28 pm revealed:
1. A hole above the Lower Level BB03I Receiving Doors.
2. The Level A Radioactive Room in an existing stair tower with radioactive material stored inside measured over 50 square feet and failed to have an automatic closure installed on the room door.
3. The 2nd Floor Projection Room neighbored a conference room. The Projection Room measured over 50 square feet and was contained storage and storage on shelves. The facility failed to separate the conference room from the Projector Room or keep the Projector Room clear of storage.
The observations were confirmed by Engineering B on the same date and time.


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4. Observation of the southeast electrical room on third west, of the west tower, on 12/01/10 at 1:00 pm, revealed that the one hour fire rated wall had two cuts for expansion joints that had not been installed and the facility failed to seal the cuts to ensure separation from the remainder of the building. Observations were acknowledged by Safety Officer E at the time of the observations.


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5. On December 1, 2010, between 8:00 A.M. and 5:30 P.M. observation revealed that the facility failed to provide a self closing device on the door to the 4 South Family Room. At the time of the survey the room was being used as a storage area. Observations were confirmed by Safety Officer E.


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6. Observation on November 30th, 2010 at 1:47 pm revealed the facility failed to seal around the duct work in the nurse call closet on the Second Floor. The observation was confirmed by interview with Engineering B on the same time and date.
7. Observation on November 30th, 2010 at 1:50 pm revealed the facility failed to seal a round piping in the low voltage room 2nd Floor. The observation was confirmed by interview with Engineering B on the same date and time.

Based on observation and staff interview, the facility failed to separate hazardous areas from use areas with smoke resisting partitions by not maintaining barriers free of penetrations. This deficient practice had the potential to affect all patients, staff and visitors.

Findings are:
Observations on 12/1/10, from 9:59 am to 10:20 am revealed:
1. Above ceiling at the South Hall Soiled Utility and Storage Room revealed penetrations in the corridor wall around pipes.
2. Above ceiling at the North Hall Mechanical Room revealed a hole around conduit in the corridor wall.
3. Above ceiling at the Isotope Storage Room revealed a hole around a cable in the corridor wall.
4. Above ceiling at the Accelerator 2 Electrical Room revealed holes around sprinkler pipe and conduit in the corridor wall.
The observations were confirmed by Engineering B on the same date and time.


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5. Observation on December 1, 2010 at 10:00 am revealed the facility failed to seal holes in the storage room in the south hall of the Cancer Center. The observation was confirmed by interview with engineering B on the same date and time.
The observations were confirmed by Engineering B on the same date and time.

Based on observation and interview, the facility failed to provide smoke resistant separation for hazardous areas. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
On November 30, 2010, between 10:30 A.M. and 5:30 P.M. observation revealed that the facility failed to provide the required separation for the Main Lobby Gift Shop. The gift shop ' s entry is open to the corridor. Observations were confirmed by Project Manager F.


21540

Based on observation and interview, the facility failed to maintain the ¿¿2-hour fire wall above the ceiling in the gift shop storage area on the ground floor for fire spread prevention purposes. This practice affected all patients due to the fact that fire and smoke could get through the noted penetration and possibly spread throughout the building. Facility census was 164 patients on date of survey, 11-30-10.

Findings are:
Observations on 11-30-10 revealed a penetration in the 2¿¿-hour wall above the ceiling in the gift shop storage area. This was a smaller hole, approximately 2 by 2 inches where abated romex wire was run through the wall. There was also a gap above the duct work in the north corner that was in need of being sealed with a fire rated material.
During an interview on 11-30-10 at 11:30AM, Engineering C agreed the wall and duct gap was in need of repair and documented this deficiency on paper and with a photograph to ensure prompt and proper repair.

Based on observation and interview, the facility failed to prohibit penetrations into and openings through an exit enclosure assembly. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
1. On 12/01/10 at 3:00 pm, observation revealed that the North Mechanical Room opened into the Central Exit Stair Enclosure, which is prohibited by the NFPA 101 Life Safety Code for hazardous areas opening into exit enclosures. Observations were acknowledged by Engineering B at the time of the observations.
2. On 12/01/10 at 3:15 pm, observation revealed that the North Mechanical Room opened into the North Exit Stair Enclosure, which is prohibited by the NFPA 101 Life Safety Code for hazardous areas opening into exit enclosures. Observations were acknowledged by Engineering B at the time of the observations.
3. On 12/01/10 at 3:30 pm, observation revealed that the South Storage Room opened into the South Exit Stair Enclosure, which is prohibited by the NFPA 101 Life Safety Code for hazardous areas opening into exit enclosures. Observations were acknowledged by Engineering B at the time of the observations.

Actual NFPA Standard: NFPA 101 Chapter 7.1.3.2 Exits.
Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following.
(a) * The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) * The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
Exception No. 1: In existing non-high-rise buildings, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 2: In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 3: One-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative.
(c) Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8.
(d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.
Exception No. 1: Openings in exit passageways in covered mall buildings as provided in Chapters 36 and 37 shall be permitted.
Exception No. 2: In buildings of Type I or Type II construction, existing fire-protection rated doors shall be permitted to interstitial spaces provided that such space meets the following criteria:
(a) The space is used solely for distribution of pipes, ducts, and conduits.
(b) The space contains no storage.
(c) The space is separated from the exit enclosure in accordance with 8.2.3.
(e) Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
(1) Electrical conduit serving the stairway
(2) Required exit doors
(3) Ductwork and equipment necessary for independent stair pressurization
(4) Water or steam piping necessary for the heating or cooling of the exit enclosure
(5) Sprinkler piping
(6) Standpipes
Exception No. 1: Existing penetrations protected in accordance with 8.2.3.2.4 shall be permitted.
Exception No. 2: Penetrations for fire alarm circuits shall be permitted within enclosures where fire alarm circuits are installed in metal conduit and penetrations are protected in accordance with 8.2.3.2.4.
(f) Penetrations or communicating openings shall be prohibited between adjacent exit enclosures.

Based on observation and staff interview, the facility failed to provide illumination in the path of egress so that failure of one bulb would not leave the area in darkness. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
Observation on 11/30/10, at 2:16 pm in the Old ER Entrance Stairwell revealed all lights were extinguished when the light switch was turned off.
The observations were confirmed by Engineering B on the same date and time.

Based on observation and interview the facility failed to maintain emergency lighting of at least 1 ½ hour duration in accordance NFPA 101, 7.9. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 80 and the census was 20.

Findings are:
Observation on December 1, 2010 at 2:00 pm revealed the emergency light in the Access Center did not work. The observation was confirmed by interview with Project Manager F

Based on observation and interview the facility failed to maintain fire alarm system components, devices or equipment installed according to NFPA 72.2.3.5.1A. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 80 and the census was 20.

Findings Are:
Observation on December 1, 2010 at 2:10 pm revealed the smoke detector in the Business Development office was to close to the heating duct. The observation was confirmed by interview with Project Manager F

Based on observation and interview the facility failed to maintain the fire alarm system with approved components, devices or equipment installed accordance with NFPA 72 & NFPA 19.3.4. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 with a census of 164.

Findings are:
1. Observation on December 1, 2010 at 8:20 am revealed the facility failed to provide a smoke detector by the separation door going into the birth center. The observation was confirmed by interview with Safety Officer E.


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2. On 12/01/10 at 1:46 pm, observations revealed that the facility failed to provide a smoke detector in the Hospitalist Sleeping Room. Observations were acknowledged and verified by Engineering B at the time of the observations.
3. On 11-30-10 at 1:41pm, observation revealed the smoke detector in the lower level corridor, just outside Health Information Management was installed less than three feet from the supply air register. Interview with Safety Officer E, revealed the facility was not aware of the requirement to prohibit installation of smoke detectors within three feet of supply air registers.
4. On 12-01-10 at 11:30am, observation revealed the smoke detector in the Helipad Room was installed less than three feet from the supply air register. Interview with Safety Officer E, revealed the facility was not aware of the requirement to prohibit installation of smoke detectors within three feet of supply air registers.


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5. On November 30, 2010, between 10:30 A.M. and 5:30 P.M. observation revealed that the facility failed to provide recommended spacing of smoke detectors to supply diffusers. The smoke detectors located in the Non-Invasive Work Room and the Respiratory Therapy Director ' s Office, were located closer that three feet form the supply diffuser. Observations were confirmed by Project Manager F.
6. On November 30, 2010, between 10:30 A.M. and 5:30 P.M. observation revealed that the facility failed to provide the proper mounting of smoke detector located in the Radiology Electrical Room. A Smoke detector hung by wires wrapped around conduit. Observations were confirmed by Project Manager F.
7. On November 30, 2010, between 10:30 A.M. and 5:30 P.M. observation revealed that the facility failed to provide smoke detection and occupant notification in the OR Sleep Room across from Room 2. Observations were confirmed by Project Manager F.
8. On December 1, 2010, between 8:00 A.M. and 5:30 P.M. observation revealed the facility failed to provide recommended spacing of smoke detectors to supply diffusers. The smoke detectors located in 3 North Staff Locker Room, 3rd floor Equipment Room, 3 North Soiled Linen, and 3 North Nurse ' s Station were located closer than three feet from the supply diffuser. Observations were confirmed by Project Manager F.

Actual NFPA Standard: NFPA 72 section 2-3.5.1*
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.
Actual NFPA Standard: NFPA 72 A-2-3.5.1
Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.

Based on observations and interview, the facility failed to provide a complete automatic supervised sprinkler system. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 with a census of 164.

Findings are:
On November 30, 2010, between 10:30 A.M. and 5:30 P.M. observation revealed that the facility failed to install a sprinkler head in the closet outside the Chief Flight Nurse ' s Office. Observations were confirmed by Project Manager F.

Based on observation and interview, the facility failed to maintain an acceptable clearance to prevent obstructions to spray patterns in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 edition. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 with a census of 164.

Findings are:
On 11/30/10 at 11:53 am, it was observed the facility failed to maintain an unacceptable obstruction to spray pattern of the sprinkler head in the kitchen behind the dishwasher, the light fixture is obstructing the spray pattern of the sprinkler head. Observations were acknowledged by Safety Officer E at the time of the observations.

Based on observation and interview, the facility failed to provide a range hood extinguishing system in accordance with NFPA 96 sec. 10-1.2 and UL-300. Cooking equipment that produces grease-laden vapors and that might be a source of ignition of grease in the hood, grease removal device, or duct shall be protected by fire-extinguishing equipment. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 with a census of 164.

Findings Are:
Observation on 11/30/10 at 11:45 am, the Kitchen ' s center range hood system was installed over ovens and a large cooking appliance which was used to brown hamburger for soups. This cooking process produces grease-laden vapors and requires the range hood to be protected by a fire extinguishing system. Interview with Safety Officer E, advised the facility was not aware that the appliance was being used for that process.

Based on observation and interview, the facility failed to secure all medical gas cylinders which were stored on the ground level (dock area). This practice affected all patients. Facility census was 164 patients on date of survey, 11-30-10.

Findings are:
Observations on 11-30-10 at 3:55 PM revealed three small helium cylinders and one " E " size oxygen cylinder were not stored properly as they stood freely and were not secured to a wall, rack or frame.
During an interview on the same date and time, Engineering C confirmed the deficiency and stated it will be corrected.

Based on observation and interview, the facility failed to provide proper storage for combustible liquids. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 with a census of 164.

Findings are:
On December 1, 2010, between 8:00 A.M. and 5:30 P.M. observations revealed a diesel fired heater with fuel in the tank stored in the west tower basement. Observations were confirmed by Engineering B.

Actual NFPA Standard:
NFPA 1, 60.2.3.5.6

Based on observation and interview the facility failed to maintain Medical gas storage and administration area in accordance with NFPA 99, 8.6.4.2 NFPA 19.3.2.3.

Findings Are:
Observation on December 1, 2010 at 9:20 am revealed the storage room in the Image Center was not marked as an oxygen storage room. The observation was confirmed by interview with Engineering B.

Based on observation and interview the facility failed to maintain Non-smoking and no smoke signs in areas where oxygen is used of stored in accordance with NFPA 19.3.2.4, NFPA 99, 8.6.4.2. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 80 and the census was 20.

Findings are:
1. Observation on December 1, 2010 at 3:00 pm revealed that the storage in nurse station of the youth unit was not marked as an oxygen storage room. The observation was confirmed by interview with Project Manager F.
2. Observation on December 1, 2010 at 3:05 pm revealed that the storage room in the Adult unit was not marked as an oxygen storage room. The observation was confirmed by interview with Project Manager F

Based on observation and interview the facility failed to maintain medical gas storage and administration areas in accordance with NFPA 99, 8.6.4.2 NFPA 19.3.2.3 This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 with a census of 164.

Findings Are:
1. Observation on November 30th 2010 at 3:53 pm revealed the mechanical room next to Room 3219 was not marked as an oxygen storage room. The Observation was confirmed by interview with Engineering B.
2. Observation on December 1, 2010 at 8:25 am revealed the 2nd Floor Clean Supply Room was not marked as an oxygen storage room. The observation was confirmed by interview with Engineering B.
3. Observation on December 1, 2010 at 9:03 am revealed the storage room on the second floor was not marked as an oxygen storage room. The observation was confirmed by interview with Engineering B.
4. Observation on December 1, 2010 at 9:03 am revealed the IC equipment storage room was not marked as an oxygen storage room. The observation was confirmed by interview with Engineering B.

Based on observation and interview the facility failed to maintain medical gas storage and an administration area in accordance with NFPA 99, 8.6.4.2 and NFPA 19.3.2.3. This deficient practice had the potential to affect all patients, staff and visitors.

Findings Are:
Observation on December 1, 2010 at 9:58 am revealed oxygen was stored in the corridor of the cancer center. The observation was confirmed by interview with Engineering B.

Based on observation and interview, in the Fitness and Rehabilitation Center, the facility did not post warning signs on a room where oxygen was being stored. The deficient practice affected one smoke compartment and all occupants in that zone.

Findings are:
On 11/30/10 at 2:05 pm, it was observed that the wheelchair storage room had four oxygen tanks being stored there and did not have the proper warning signage outside the storage room door. Observations were acknowledged by Safety Officer E at the time of the observations.

Based on observation and staff interview, the facility failed to label all components of the emergency generators. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
Observation on 11/30/10, at 2:55 pm revealed the facility failed to label all transfer switches for the CAT and John Deere Generators. Therefore, the configuration of all emergency generator circuitry failed to be verified.
The observations were confirmed by Engineering B on the same date and time.

Based on observation and interview the facility failed to maintain equipment wiring and equipment in accordance with NFPA 70 National Electrical Code. 9.1.2. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 80 and the census was 20.

Findings Are:
1. Observation on December 1, 2010 at 2:00 pm revealed a refrigerator was plug into a power strip in the Buffalo Community Partners area. The observation was confirmed by interview with Project Manager F.
2. Observation on December 1, 2010 at 2:00 pm revealed a cover was missing off an electrical box on the east wall of the boiler room. The observation was confirmed by interview with Project Manager F.

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with NFPA 70. This deficient practice had the potential to affect all patients, staff and visitors.
1. Observation on December 1, 2010 at 9:58 am revealed storage in front of electrical panel on the east wall of the electrical room in the cancer center. The observation was confirmed by interview with Engineering B.
2. Observation on December 1, 2010 at 9:58 am revealed the covers had been left off of the electrical box and electrical plug in the nurse closet. The observation was confirmed by interview with Engineering B.

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with NFPA 70. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
Observations on 11/30/10, from 1:33 pm to 2:35 pm revealed:
1. An open junction box in the Lower Level Air Handler 19 Room on the North Elevator Shaft.
2. Above ceiling at the Nutrition Services Entry above the " Café " sign revealed open wiring protruding from electrical conduits.
3. In the Level A Lab the Blood Sample Cooler was plugged into a pigtail extension cord.
The observations were confirmed by Engineering B on the same date and time.


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4. On December 1, 2010, between 8:00 A.M. and 5:30 P.M. observations revealed the use of an extension cord to power the electronics shop located in the basement of the West Tower. The extension cord hung from overhead pipes and conduit. Observations were confirmed by Engineering B.


04548

5. Observation on 11/30/10 at 11:50 am, revealed in the Kitchen under the south range hood, there was a power strip suspended by the cord, which had a microwave and deep fat fryer plugged into it. Observations were acknowledged and verified by Safety Officer E at the time of the observations.

Based on observation and interview, the facility failed to maintain the use of relocatable power taps. Relocatable power taps are not permitted in areas of health care occupancies regularly occupied by patients. This includes general patient care areas and critical patient care areas.

General care areas include patient bedrooms, examining rooms, treatment rooms, clinics and similar areas where it is intended that the patient will come in contact with ordinary appliances such as nurse call systems, electrical beds, examining lamps, telephones and entertainment devices such as radios, televisions and computers. This will also include common spaces such as corridors, lounges, dining rooms and similarly occupied spaces where electrical appliances noted above may be found. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
6. Observation on 11-30-10 at 3:07 pm, revealed that the Cath Lab secretary/ reception desk which was open to the corridor and treatment rooms within this facility was using an unapproved power strip. Observations were acknowledged and verified by Safety Officer E at the time of the observations.

7. Observation on 12-01-10 at 9:10 am, revealed that patient room 3312 within this facility was using an unapproved power strip. Observations were acknowledged and verified by Project Manager F at the time of the observations.

8. Observation on 12-01-10 at 9:30 am, revealed that Occupational Therapy Room within this facility was using an unapproved power strip. Observations were acknowledged and verified by Project Manager F at the time of the observations.

Based on observation and interview the facility failed to maintain the proper spacing between electrical outlets and switches and the alcohol-based hand rub dispensers, NFPA 101 19.3.2.7

Findings Are:
Observation on December 1, 2010 at 10:02 am revealed the alcohol-based hand rub dispensers was located above an electrical switch in house keeping in the south hall. The observation was confirmed by interview with Engineering B.

Based on observation and staff interview, the facility failed to separate use areas from corridors with smoke resisting partitions or with barrier ratings specified by facility floor plans by not maintaining barriers free of penetrations. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
Observations on 12/1/10, from 8:27 am to 8:29 am revealed:
1. Above ceiling at Room 3261 revealed a one foot square hole around ductwork in the corridor wall.
2. Above ceiling from Room 3260 to 3250 the corridor wall failed to extend to the floor above. From the Conference Room to the Lactation Consultant Room, the corridor wall failed to extend to the floor above.
The observations were confirmed by Engineering B on the same date and time.


21540


Observations on 11/30/10, from 11:10 AM to 12-1-10 at 4:10 PM revealed:
3. A penetration in the ¿¿2-hour wall above the ceiling in the " mammo " area. This hole was rather large and a good portion of the wall was missing (approximately 3 - 4 feet of brick was gone).
4. A penetration in the ¿¿2-hour wall above the ceiling in the ambulatory care center area which is the other side of the " mammo " wall.
5. A penetration, approximately 2 inches in diameter in the 2¿¿-hour wall above the ceiling in the Radiology bathroom area (near supervisor ' s office). There were also pipes running through the ceiling that were in need of fire rated gaskets or fire caulking material to ensure no vertical smoke or fire spread.
6. A penetration in the ¿¿2-hour wall above the ceiling in the Radiology west side entry / exit vestibule area. This hole was approximately 1 inch by 3 inches in size.
7. A penetration in the 2¿¿-hour fire rated wall above the ceiling in the dock area. There was a fairly large hole noted behind several electrical conduits and also a small hole near there. These penetrations were above a set of 90 minute fire rated doors. There were penetrations on both sides of this wall above the doors. Some of the penetrations were stuffed with fiberglass insulation but not with a rated material. Along with the conduit holes, other penetrations were along a drywall seam where communication wires were going through the wall.
8. There were penetrations in the 1¿¿-hour rated smoke wall above the ceiling in the " Endo " (Endoscopy) area. There was an 8-inch by 8-inch hole noted around some electrical conduit. There was also a hole around a fire sprinkler pipe labeled " Fire Main " - this was a 4-inch pipe that went through a 6-inch hole. These penetrations were (again) near the " Endo " area, above the Dr. portraits.
9. A penetration in the 1¿¿-hour fire wall above the ceiling in the Radiology lounge area. This was a smaller hole (less than 2-inches diameter) around some communication wires.
10. A penetration in the 1¿¿-hour smoke wall above the ceiling in the Radiology entrance area. This area is adjacent to the vending machine area and the deficiency was noted above a set of 45-minute rated doors in the corridor. There were holes around electrical conduit, a " tube station " pipe had a hole around it (approximately 1 to 2-inches larger than needed and there were communication wires with holes around them that needed to be sealed with fire caulk or another approved material.
11. A penetration in the ¿¿1-hour wall above the ceiling in the in the corridor of compartment 1J (per blue print) on the ground floor. This penetration was not properly sealed. It had been sealed with non-rated polyurethane expanding foam. Another larger penetration (Approximately 1-foot by 2-feet) nearby had also been sealed with foam insulation panels instead of drywall.
12. A penetration in the 4¿¿-hour fire rated wall above the ceiling in the Kearney Imaging Center area. This was above a set of 3-hour rated doors in the corridor and the penetration was around electrical conduit, approximately 2 - 3-inches in diameter.
13. A penetration in the 2¿¿-hour rated smoke wall above the ceiling in the Doctor Office area (across from outpatient room 4, off of the corridor) on the ground floor. There were holes through this brick wall where it had been penetrated to run electrical conduits through. Each hole was approximately 1-inch larger than it needed to be.
14. A penetration in the ¿¿2-hour rated smoke wall above the ceiling in the Operating Room entrance area (near stairs, in corridor). There were large chunks of the top layer of drywall missing (there were two layers of 5/8 " drywall) in one area there was a 2 by 2-foot section missing and also an 8 by 8-inch section of the top layer of drywall missing. The missing layers could allow flames and smoke to penetrate this barrier sooner than expected.
15. There were penetrations in the 2¿¿-hour rated wall above the ceiling in the Care management meeting room and offices area. There was a 2-inch by 3-inch hole around some flex conduit and also several smaller holes above the ceiling of office C.
16. There were penetrations in the 2¿¿-hour wall above the ceiling and fire rated doors in between the hospital and Medical Office Building (corridor) on the ground floor. These were smaller holes around electrical conduit and communication wires.
17. There were penetrations in the 1¿¿-hour wall above the ceiling in the West tower area 1A (per blue print) area " Emporium " fire wall. There were holes around sprinkler pipes and electrical conduit. There were also miscellaneous holes around communication wires and also ventilation ducts.
18. A penetration in the ¿¿1-hour wall above the ceiling in the West tower office area (near office 9) area. There was a 3-inch by 5-inch rectangular hole cut out. This was pointed out to be a problem because smoke and fire could easily pass through this opening.
19. A penetration in the ¿¿1-hour wall above the ceiling in the West Tower area (near stairs). Near the stairwell there were holes around pipes (down in the soffit). Each pipe had a hole approximately 1-inch greater than it needed to be. These are in need of rated gaskets or fire caulk to ensure no spreading of smoke or fire.
20. The observations were confirmed by Engineering C and D on the same dates and time frame. Engineering C and D both documented the deficiencies on paper and with photographs to ensure prompt and proper repair.
21. Observation on the 2nd Floor above ceiling revealed a hole in the pre-cast concrete ceiling above the Stair Tower 2B15E Door.
The observations were confirmed by Engineering C and D on the same dates and time frame. Engineering C and D both documented the deficiencies on paper and with photographs to ensure prompt and proper repair.

Based on observation and staff interview, the facility failed to enclose an elevator shaft and an atrium with one hour fire resistance construction by not maintaining barriers free of penetrations. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 80 and the census was 20.

Findings are:
Observations on 12/1/10, from 1:49 pm to 2:55 pm revealed:
1. Above ceiling at the Atrium Fire Doors near the Revenue Realization Center had a hole around cables in the barrier wall.
2. Above ceiling at the Atrium Fire Doors outside of the Adult Unit revealed penetrations in the barrier wall.
3. Above ceiling on the Lower Level at the Freight Elevator revealed a hole around copper pipe in the shaft wall.
The observations were confirmed by Safety Officer E on the same date and time.

Based on observation and staff interview, the facility failed to enclose an elevator shaft and stair tower walls with one hour fire resistance construction. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
1. Observations on 11/30/10, from 11:55 am to 4:12 pm revealed:

2. Observation on the Lower Level above ceiling revealed a penetration in the elevator shaft of Elevator 6.

Observations on Level A revealed:
3. Above ceiling in the Clinical Engineering Break Room revealed a one foot square hole for conduits and holes around conduits above the stair tower door.
4. Inside the ER Entrance was a two story stairwell. At the bottom of the stairs were a set of double doors that had a fire resistance rating of 20 minutes with wire glass. The doors did not have latching hardware. The facility failed to provide doors with latching hardware and a fire resistance rating of one hour.

5. Observation on the 2nd Floor above ceiling revealed a hole in the pre-cast concrete ceiling above the Stair Tower 2B15E Door.
The observations were confirmed by Engineering B on the same date and time.

Actual NFPA Standard: NFPA 101 Chapter 7.1.3.2 Exits.
Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following.
(a) * The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.

Based on observation and interview, the facility failed to assure barrier doors were equipped with hold-open devices that actuated by a local smoke detector. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
On November 30, 2010, between 10:30 A.M. and 5:30 P.M. observation revealed that the fire doors that were used as smoke separation doors, between Radiology and Staff Elevators do not have smoke detection located within five feet of the doors. Observations were confirmed by Project Manager F.

Based on observation and staff interview, the facility failed to accurately mark the means of egress when not readily apparent. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
Observations on 11/30/10, at 2:07 pm on Level A revealed an exit sign marked the A600 Stairs as an exit. The A600 Stair Door was marked " not an exit " because the stairs did not exit to the outside. The facility failed to remove the exit sign marking the A600 Stairs as an exit.
The observations were confirmed by Engineering B on the same date and time.

Based on observation and staff interview, the facility failed to provide smoke barriers with construction of at least one half hour fire resistance rating by not maintaining barriers free of penetrations. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
1. Observations on 11/30/10, from 11:32 am to 12/1/10, 3:44 pm revealed:

Observations on the Lower Level revealed:
2. Holes around electrical conduits in the barrier above the BB01J Double Doors.
3. Holes around communication wires in the barrier above the BC05C Double Doors.

4. Observation on the 2nd Floor revealed a hole around a wire in the barrier above the 2C024 Double Doors.
The observations were confirmed by Engineering B on the same date and time.

Based on observation and staff interview, the facility failed to provide smoke barriers with construction of at least one half hour fire resistance rating by not maintaining barriers free of penetrations. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 80 and the census was 20.

Findings are:
Observations on 12/1/10, from 2:32 pm to 2:59 pm revealed:
1. Above ceiling in the Fan Coil Attic Space of the Lower Level Youth Unit revealed a 2 foot square hole cut in the smoke barrier wall.
2. Above ceiling at the corridor double doors leading into the mechanical room outside of the Gym revealed holes around cables in the barrier wall.
The observations were confirmed by Safety Officer E on the same date and time.

Based on observation and interview, the facility failed to maintain doors in smoke barriers that resist the passage of smoke. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
On November 30, 2010, between 10:30 A.M. and 5:30 P.M. observation revealed that the smoke separation doors, between Radiology and Staff Elevators do not properly close to create a barrier that would resist the passage of smoke. Observations were confirmed by Project Manager F.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
Observations on 11/30/10, from 1:39 pm to 3:28 pm revealed:
1. A hole above the Lower Level BB03I Receiving Doors.
2. The Level A Radioactive Room in an existing stair tower with radioactive material stored inside measured over 50 square feet and failed to have an automatic closure installed on the room door.
3. The 2nd Floor Projection Room neighbored a conference room. The Projection Room measured over 50 square feet and was contained storage and storage on shelves. The facility failed to separate the conference room from the Projector Room or keep the Projector Room clear of storage.
The observations were confirmed by Engineering B on the same date and time.


04548

4. Observation of the southeast electrical room on third west, of the west tower, on 12/01/10 at 1:00 pm, revealed that the one hour fire rated wall had two cuts for expansion joints that had not been installed and the facility failed to seal the cuts to ensure separation from the remainder of the building. Observations were acknowledged by Safety Officer E at the time of the observations.


15537

5. On December 1, 2010, between 8:00 A.M. and 5:30 P.M. observation revealed that the facility failed to provide a self closing device on the door to the 4 South Family Room. At the time of the survey the room was being used as a storage area. Observations were confirmed by Safety Officer E.


04525

6. Observation on November 30th, 2010 at 1:47 pm revealed the facility failed to seal around the duct work in the nurse call closet on the Second Floor. The observation was confirmed by interview with Engineering B on the same time and date.
7. Observation on November 30th, 2010 at 1:50 pm revealed the facility failed to seal a round piping in the low voltage room 2nd Floor. The observation was confirmed by interview with Engineering B on the same date and time.

Based on observation and staff interview, the facility failed to separate hazardous areas from use areas with smoke resisting partitions by not maintaining barriers free of penetrations. This deficient practice had the potential to affect all patients, staff and visitors.

Findings are:
Observations on 12/1/10, from 9:59 am to 10:20 am revealed:
1. Above ceiling at the South Hall Soiled Utility and Storage Room revealed penetrations in the corridor wall around pipes.
2. Above ceiling at the North Hall Mechanical Room revealed a hole around conduit in the corridor wall.
3. Above ceiling at the Isotope Storage Room revealed a hole around a cable in the corridor wall.
4. Above ceiling at the Accelerator 2 Electrical Room revealed holes around sprinkler pipe and conduit in the corridor wall.
The observations were confirmed by Engineering B on the same date and time.


04525

5. Observation on December 1, 2010 at 10:00 am revealed the facility failed to seal holes in the storage room in the south hall of the Cancer Center. The observation was confirmed by interview with engineering B on the same date and time.
The observations were confirmed by Engineering B on the same date and time.

Based on observation and interview, the facility failed to provide smoke resistant separation for hazardous areas. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
On November 30, 2010, between 10:30 A.M. and 5:30 P.M. observation revealed that the facility failed to provide the required separation for the Main Lobby Gift Shop. The gift shop ' s entry is open to the corridor. Observations were confirmed by Project Manager F.


21540

Based on observation and interview, the facility failed to maintain the ¿¿2-hour fire wall above the ceiling in the gift shop storage area on the ground floor for fire spread prevention purposes. This practice affected all patients due to the fact that fire and smoke could get through the noted penetration and possibly spread throughout the building. Facility census was 164 patients on date of survey, 11-30-10.

Findings are:
Observations on 11-30-10 revealed a penetration in the 2¿¿-hour wall above the ceiling in the gift shop storage area. This was a smaller hole, approximately 2 by 2 inches where abated romex wire was run through the wall. There was also a gap above the duct work in the north corner that was in need of being sealed with a fire rated material.
During an interview on 11-30-10 at 11:30AM, Engineering C agreed the wall and duct gap was in need of repair and documented this deficiency on paper and with a photograph to ensure prompt and proper repair.

Based on observation and interview, the facility failed to prohibit penetrations into and openings through an exit enclosure assembly. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
1. On 12/01/10 at 3:00 pm, observation revealed that the North Mechanical Room opened into the Central Exit Stair Enclosure, which is prohibited by the NFPA 101 Life Safety Code for hazardous areas opening into exit enclosures. Observations were acknowledged by Engineering B at the time of the observations.
2. On 12/01/10 at 3:15 pm, observation revealed that the North Mechanical Room opened into the North Exit Stair Enclosure, which is prohibited by the NFPA 101 Life Safety Code for hazardous areas opening into exit enclosures. Observations were acknowledged by Engineering B at the time of the observations.
3. On 12/01/10 at 3:30 pm, observation revealed that the South Storage Room opened into the South Exit Stair Enclosure, which is prohibited by the NFPA 101 Life Safety Code for hazardous areas opening into exit enclosures. Observations were acknowledged by Engineering B at the time of the observations.

Actual NFPA Standard: NFPA 101 Chapter 7.1.3.2 Exits.
Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following.
(a) * The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less.
(b) * The separation shall have not less than a 2-hour fire resistance rating where the exit connects four or more stories. The separation shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having not less than a 2-hour fire resistance rating.
Exception No. 1: In existing non-high-rise buildings, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 2: In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have not less than a 1-hour fire resistance rating.
Exception No. 3: One-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative.
(c) Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8.
(d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.
Exception No. 1: Openings in exit passageways in covered mall buildings as provided in Chapters 36 and 37 shall be permitted.
Exception No. 2: In buildings of Type I or Type II construction, existing fire-protection rated doors shall be permitted to interstitial spaces provided that such space meets the following criteria:
(a) The space is used solely for distribution of pipes, ducts, and conduits.
(b) The space contains no storage.
(c) The space is separated from the exit enclosure in accordance with 8.2.3.
(e) Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
(1) Electrical conduit serving the stairway
(2) Required exit doors
(3) Ductwork and equipment necessary for independent stair pressurization
(4) Water or steam piping necessary for the heating or cooling of the exit enclosure
(5) Sprinkler piping
(6) Standpipes
Exception No. 1: Existing penetrations protected in accordance with 8.2.3.2.4 shall be permitted.
Exception No. 2: Penetrations for fire alarm circuits shall be permitted within enclosures where fire alarm circuits are installed in metal conduit and penetrations are protected in accordance with 8.2.3.2.4.
(f) Penetrations or communicating openings shall be prohibited between adjacent exit enclosures.

Based on observation and staff interview, the facility failed to provide illumination in the path of egress so that failure of one bulb would not leave the area in darkness. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
Observation on 11/30/10, at 2:16 pm in the Old ER Entrance Stairwell revealed all lights were extinguished when the light switch was turned off.
The observations were confirmed by Engineering B on the same date and time.

Based on observation and interview the facility failed to maintain emergency lighting of at least 1 ½ hour duration in accordance NFPA 101, 7.9. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 80 and the census was 20.

Findings are:
Observation on December 1, 2010 at 2:00 pm revealed the emergency light in the Access Center did not work. The observation was confirmed by interview with Project Manager F

Based on observation and interview the facility failed to maintain fire alarm system components, devices or equipment installed according to NFPA 72.2.3.5.1A. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 80 and the census was 20.

Findings Are:
Observation on December 1, 2010 at 2:10 pm revealed the smoke detector in the Business Development office was to close to the heating duct. The observation was confirmed by interview with Project Manager F

Based on observation and interview the facility failed to maintain the fire alarm system with approved components, devices or equipment installed accordance with NFPA 72 & NFPA 19.3.4. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 with a census of 164.

Findings are:
1. Observation on December 1, 2010 at 8:20 am revealed the facility failed to provide a smoke detector by the separation door going into the birth center. The observation was confirmed by interview with Safety Officer E.


04548

2. On 12/01/10 at 1:46 pm, observations revealed that the facility failed to provide a smoke detector in the Hospitalist Sleeping Room. Observations were acknowledged and verified by Engineering B at the time of the observations.
3. On 11-30-10 at 1:41pm, observation revealed the smoke detector in the lower level corridor, just outside Health Information Management was installed less than three feet from the supply air register. Interview with Safety Officer E, revealed the facility was not aware of the requirement to prohibit installation of smoke detectors within three feet of supply air registers.
4. On 12-01-10 at 11:30am, observation revealed the smoke detector in the Helipad Room was installed less than three feet from the supply air register. Interview with Safety Officer E, revealed the facility was not aware of the requirement to prohibit installation of smoke detectors within three feet of supply air registers.


15537

5. On November 30, 2010, between 10:30 A.M. and 5:30 P.M. observation revealed that the facility failed to provide recommended spacing of smoke detectors to supply diffusers. The smoke detectors located in the Non-Invasive Work Room and the Respiratory Therapy Director ' s Office, were located closer that three feet form the supply diffuser. Observations were confirmed by Project Manager F.
6. On November 30, 2010, between 10:30 A.M. and 5:30 P.M. observation revealed that the facility failed to provide the proper mounting of smoke detector located in the Radiology Electrical Room. A Smoke detector hung by wires wrapped around conduit. Observations were confirmed by Project Manager F.
7. On November 30, 2010, between 10:30 A.M. and 5:30 P.M. observation revealed that the facility failed to provide smoke detection and occupant notification in the OR Sleep Room across from Room 2. Observations were confirmed by Project Manager F.
8. On December 1, 2010, between 8:00 A.M. and 5:30 P.M. observation revealed the facility failed to provide recommended spacing of smoke detectors to supply diffusers. The smoke detectors located in 3 North Staff Locker Room, 3rd floor Equipment Room, 3 North Soiled Linen, and 3 North Nurse ' s Station were located closer than three feet from the supply diffuser. Observations were confirmed by Project Manager F.

Actual NFPA Standard: NFPA 72 section 2-3.5.1*
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.
Actual NFPA Standard: NFPA 72 A-2-3.5.1
Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.

Based on observations and interview, the facility failed to provide a complete automatic supervised sprinkler system. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 with a census of 164.

Findings are:
On November 30, 2010, between 10:30 A.M. and 5:30 P.M. observation revealed that the facility failed to install a sprinkler head in the closet outside the Chief Flight Nurse ' s Office. Observations were confirmed by Project Manager F.

Based on observation and interview, the facility failed to maintain an acceptable clearance to prevent obstructions to spray patterns in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 edition. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 with a census of 164.

Findings are:
On 11/30/10 at 11:53 am, it was observed the facility failed to maintain an unacceptable obstruction to spray pattern of the sprinkler head in the kitchen behind the dishwasher, the light fixture is obstructing the spray pattern of the sprinkler head. Observations were acknowledged by Safety Officer E at the time of the observations.

Based on observation and interview, the facility failed to provide a range hood extinguishing system in accordance with NFPA 96 sec. 10-1.2 and UL-300. Cooking equipment that produces grease-laden vapors and that might be a source of ignition of grease in the hood, grease removal device, or duct shall be protected by fire-extinguishing equipment. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 with a census of 164.

Findings Are:
Observation on 11/30/10 at 11:45 am, the Kitchen ' s center range hood system was installed over ovens and a large cooking appliance which was used to brown hamburger for soups. This cooking process produces grease-laden vapors and requires the range hood to be protected by a fire extinguishing system. Interview with Safety Officer E, advised the facility was not aware that the appliance was being used for that process.

Based on observation and interview, the facility failed to secure all medical gas cylinders which were stored on the ground level (dock area). This practice affected all patients. Facility census was 164 patients on date of survey, 11-30-10.

Findings are:
Observations on 11-30-10 at 3:55 PM revealed three small helium cylinders and one " E " size oxygen cylinder were not stored properly as they stood freely and were not secured to a wall, rack or frame.
During an interview on the same date and time, Engineering C confirmed the deficiency and stated it will be corrected.

Based on observation and interview, the facility failed to provide proper storage for combustible liquids. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 with a census of 164.

Findings are:
On December 1, 2010, between 8:00 A.M. and 5:30 P.M. observations revealed a diesel fired heater with fuel in the tank stored in the west tower basement. Observations were confirmed by Engineering B.

Actual NFPA Standard:
NFPA 1, 60.2.3.5.6

Based on observation and interview the facility failed to maintain Medical gas storage and administration area in accordance with NFPA 99, 8.6.4.2 NFPA 19.3.2.3.

Findings Are:
Observation on December 1, 2010 at 9:20 am revealed the storage room in the Image Center was not marked as an oxygen storage room. The observation was confirmed by interview with Engineering B.

Based on observation and interview the facility failed to maintain Non-smoking and no smoke signs in areas where oxygen is used of stored in accordance with NFPA 19.3.2.4, NFPA 99, 8.6.4.2. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 80 and the census was 20.

Findings are:
1. Observation on December 1, 2010 at 3:00 pm revealed that the storage in nurse station of the youth unit was not marked as an oxygen storage room. The observation was confirmed by interview with Project Manager F.
2. Observation on December 1, 2010 at 3:05 pm revealed that the storage room in the Adult unit was not marked as an oxygen storage room. The observation was confirmed by interview with Project Manager F

Based on observation and interview the facility failed to maintain medical gas storage and administration areas in accordance with NFPA 99, 8.6.4.2 NFPA 19.3.2.3 This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 with a census of 164.

Findings Are:
1. Observation on November 30th 2010 at 3:53 pm revealed the mechanical room next to Room 3219 was not marked as an oxygen storage room. The Observation was confirmed by interview with Engineering B.
2. Observation on December 1, 2010 at 8:25 am revealed the 2nd Floor Clean Supply Room was not marked as an oxygen storage room. The observation was confirmed by interview with Engineering B.
3. Observation on December 1, 2010 at 9:03 am revealed the storage room on the second floor was not marked as an oxygen storage room. The observation was confirmed by interview with Engineering B.
4. Observation on December 1, 2010 at 9:03 am revealed the IC equipment storage room was not marked as an oxygen storage room. The observation was confirmed by interview with Engineering B.

Based on observation and interview the facility failed to maintain medical gas storage and an administration area in accordance with NFPA 99, 8.6.4.2 and NFPA 19.3.2.3. This deficient practice had the potential to affect all patients, staff and visitors.

Findings Are:
Observation on December 1, 2010 at 9:58 am revealed oxygen was stored in the corridor of the cancer center. The observation was confirmed by interview with Engineering B.

Based on observation and interview, in the Fitness and Rehabilitation Center, the facility did not post warning signs on a room where oxygen was being stored. The deficient practice affected one smoke compartment and all occupants in that zone.

Findings are:
On 11/30/10 at 2:05 pm, it was observed that the wheelchair storage room had four oxygen tanks being stored there and did not have the proper warning signage outside the storage room door. Observations were acknowledged by Safety Officer E at the time of the observations.

Based on observation and staff interview, the facility failed to label all components of the emergency generators. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
Observation on 11/30/10, at 2:55 pm revealed the facility failed to label all transfer switches for the CAT and John Deere Generators. Therefore, the configuration of all emergency generator circuitry failed to be verified.
The observations were confirmed by Engineering B on the same date and time.

Based on observation and interview the facility failed to maintain equipment wiring and equipment in accordance with NFPA 70 National Electrical Code. 9.1.2. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 80 and the census was 20.

Findings Are:
1. Observation on December 1, 2010 at 2:00 pm revealed a refrigerator was plug into a power strip in the Buffalo Community Partners area. The observation was confirmed by interview with Project Manager F.
2. Observation on December 1, 2010 at 2:00 pm revealed a cover was missing off an electrical box on the east wall of the boiler room. The observation was confirmed by interview with Project Manager F.

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with NFPA 70. This deficient practice had the potential to affect all patients, staff and visitors.
1. Observation on December 1, 2010 at 9:58 am revealed storage in front of electrical panel on the east wall of the electrical room in the cancer center. The observation was confirmed by interview with Engineering B.
2. Observation on December 1, 2010 at 9:58 am revealed the covers had been left off of the electrical box and electrical plug in the nurse closet. The observation was confirmed by interview with Engineering B.

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with NFPA 70. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
Observations on 11/30/10, from 1:33 pm to 2:35 pm revealed:
1. An open junction box in the Lower Level Air Handler 19 Room on the North Elevator Shaft.
2. Above ceiling at the Nutrition Services Entry above the " Café " sign revealed open wiring protruding from electrical conduits.
3. In the Level A Lab the Blood Sample Cooler was plugged into a pigtail extension cord.
The observations were confirmed by Engineering B on the same date and time.


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4. On December 1, 2010, between 8:00 A.M. and 5:30 P.M. observations revealed the use of an extension cord to power the electronics shop located in the basement of the West Tower. The extension cord hung from overhead pipes and conduit. Observations were confirmed by Engineering B.


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5. Observation on 11/30/10 at 11:50 am, revealed in the Kitchen under the south range hood, there was a power strip suspended by the cord, which had a microwave and deep fat fryer plugged into it. Observations were acknowledged and verified by Safety Officer E at the time of the observations.

Based on observation and interview, the facility failed to maintain the use of relocatable power taps. Relocatable power taps are not permitted in areas of health care occupancies regularly occupied by patients. This includes general patient care areas and critical patient care areas.

General care areas include patient bedrooms, examining rooms, treatment rooms, clinics and similar areas where it is intended that the patient will come in contact with ordinary appliances such as nurse call systems, electrical beds, examining lamps, telephones and entertainment devices such as radios, televisions and computers. This will also include common spaces such as corridors, lounges, dining rooms and similarly occupied spaces where electrical appliances noted above may be found. This deficient practice had the potential to affect all patients, staff and visitors. The facility capacity is 187 and the census was 164.

Findings are:
6. Observation on 11-30-10 at 3:07 pm, revealed that the Cath Lab secretary/ reception desk which was open to the corridor and treatment rooms within this facility was using an unapproved power strip. Observations were acknowledged and verified by Safety Officer E at the time of the observations.

7. Observation on 12-01-10 at 9:10 am, revealed that patient room 3312 within this facility was using an unapproved power strip. Observations were acknowledged and verified by Project Manager F at the time of the observations.

8. Observation on 12-01-10 at 9:30 am, revealed that Occupational Therapy Room within this facility was using an unapproved power strip. Observations were acknowledged and verified by Project Manager F at the time of the observations.