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The facility did not ensure that doors in smoke partitions were held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the required manual alarm system and either a required smoke detection system and automatic sprinkler system as required by the referenced LSC.

On 11/26/12 at 10:30 AM, the surveyor while accompanied by the Director Safety and Security Department and the Executive Director of Facilities Management observed that the smoke barrier doors in the Maternity and Women ' s Health Unit were obstructed from closing by production equipment, belonging to a production company for the filming of a TV show, that did not allow the doors to automatically closed when released from the magnetic hold open devices.

The facility did not ensure that hazardous areas protected by an automatic extinguishing system were separated by smoke resisting partitions and self-closing doors as required by 19.3.2.1

On 11/26/12 at 10:27 AM, the surveyor while accompanied by the Director Safety and Security Department and the Executive Director of Facilities Management observed that door closers were not provided on the doors to the patient care rooms on the patient occupied third floor (seventeen patients), Whittingham/Special Care Pavilion, Maternity and Women ' s Health Unit that were be utilized as storage rooms by a production company for the filming of a TV show in order to maintain the required smoke resistance assembly in an opening to a hazardous area.

The facility did not ensure that soled linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity and Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended as required by the referenced LSC.

On 11/26/12 at various times throughout the survey the surveyor, accompanied by the Director of Engineering, observed that mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) being utilized throughout the entire facility were not located in a room protected as a hazardous area when not attended as required by the referenced LSC standard.

The facility did not ensure that solid linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity and Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended as required by the referenced LSC.

On 11/26/12 at various times throughout the survey the surveyor, accompanied by the Director of Engineering, observed that mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) being utilized throughout the entire facility were not located in a room protected as a hazardous area when not attended as required by the referenced LSC standard.

The facility did not ensure that means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10

On 11/26/12 at 10:25 AM, the surveyor while accompanied by the Director Safety and Security Department and the Executive Director of Facilities Management observed the means of egress on the patient occupied third floor (seventeen patients), Whittingham/Special Care Pavilion, Maternity and Women ' s Health Unit were not maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency; i.e., production equipment and furniture for the filming of a TV show was in use and/or stored in exit corridors of the unit.

The facility did not ensure that solid linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity and Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended as required by the referenced LSC.

On 11/26/12 at various times throughout the survey the surveyor, accompanied by the Director of Engineering, observed that mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) being utilized throughout the entire facility were not located in a room protected as a hazardous area when not attended as required by the referenced LSC standard.

The facility did not ensure that electrical devices in-patient care areas were being inspected as required in NFPA 99 " Health Care Facilities " .

On 11/26/12 at 12:30 PM, the Director Safety and Security Department and the Executive Director of Facilities Management did not provide the surveyor with documentation to indicate that electrical equipment used by a production company for the filming of a TV show on the patient occupied third floor (seventeen patients), Whittingham/Special Care Pavilion, Maternity and Women ' s Health Unit were inspected as required in NFPA 99, Section 7-5.1.3., 7-5.2.2.1 and 7-6.2.1.2 and as part of the facilities preventive maintenance program; i.e., inspection and/or testing for physical integrity, resistance, leakage current tests and chassis leakage current was not conducted and recorded by the facility before the equipment was put into service by the production company.

The facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99 " Health Care Facilities " .

On 11/27/12 at 1:00 PM , the surveyor was not provided with documentation by a member of Facilities Management to indicate that electrical receptacle outlets in patient areas in The Tully Center are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3., and as part of the facilities preventive maintenance program; i.e., last documented testing of outlets was conducted 09/2003.

The facility did not ensure that doors in smoke partitions were held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the required manual alarm system and either a required smoke detection system and automatic sprinkler system as required by the referenced LSC.

On 11/26/12 at 10:30 AM, the surveyor while accompanied by the Director Safety and Security Department and the Executive Director of Facilities Management observed that the smoke barrier doors in the Maternity and Women ' s Health Unit were obstructed from closing by production equipment, belonging to a production company for the filming of a TV show, that did not allow the doors to automatically closed when released from the magnetic hold open devices.

The facility did not ensure that hazardous areas protected by an automatic extinguishing system were separated by smoke resisting partitions and self-closing doors as required by 19.3.2.1

On 11/26/12 at 10:27 AM, the surveyor while accompanied by the Director Safety and Security Department and the Executive Director of Facilities Management observed that door closers were not provided on the doors to the patient care rooms on the patient occupied third floor (seventeen patients), Whittingham/Special Care Pavilion, Maternity and Women ' s Health Unit that were be utilized as storage rooms by a production company for the filming of a TV show in order to maintain the required smoke resistance assembly in an opening to a hazardous area.

The facility did not ensure that soled linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity and Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended as required by the referenced LSC.

On 11/26/12 at various times throughout the survey the surveyor, accompanied by the Director of Engineering, observed that mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) being utilized throughout the entire facility were not located in a room protected as a hazardous area when not attended as required by the referenced LSC standard.

The facility did not ensure that solid linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity and Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended as required by the referenced LSC.

On 11/26/12 at various times throughout the survey the surveyor, accompanied by the Director of Engineering, observed that mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) being utilized throughout the entire facility were not located in a room protected as a hazardous area when not attended as required by the referenced LSC standard.

The facility did not ensure that means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10

On 11/26/12 at 10:25 AM, the surveyor while accompanied by the Director Safety and Security Department and the Executive Director of Facilities Management observed the means of egress on the patient occupied third floor (seventeen patients), Whittingham/Special Care Pavilion, Maternity and Women ' s Health Unit were not maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency; i.e., production equipment and furniture for the filming of a TV show was in use and/or stored in exit corridors of the unit.

The facility did not ensure that solid linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity and Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended as required by the referenced LSC.

On 11/26/12 at various times throughout the survey the surveyor, accompanied by the Director of Engineering, observed that mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) being utilized throughout the entire facility were not located in a room protected as a hazardous area when not attended as required by the referenced LSC standard.

The facility did not ensure that electrical devices in-patient care areas were being inspected as required in NFPA 99 " Health Care Facilities " .

On 11/26/12 at 12:30 PM, the Director Safety and Security Department and the Executive Director of Facilities Management did not provide the surveyor with documentation to indicate that electrical equipment used by a production company for the filming of a TV show on the patient occupied third floor (seventeen patients), Whittingham/Special Care Pavilion, Maternity and Women ' s Health Unit were inspected as required in NFPA 99, Section 7-5.1.3., 7-5.2.2.1 and 7-6.2.1.2 and as part of the facilities preventive maintenance program; i.e., inspection and/or testing for physical integrity, resistance, leakage current tests and chassis leakage current was not conducted and recorded by the facility before the equipment was put into service by the production company.

The facility did not ensure that electrical receptacle outlets in-patient areas were being inspected at least annually as required in NFPA 99 " Health Care Facilities " .

On 11/27/12 at 1:00 PM , the surveyor was not provided with documentation by a member of Facilities Management to indicate that electrical receptacle outlets in patient areas in The Tully Center are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3., and as part of the facilities preventive maintenance program; i.e., last documented testing of outlets was conducted 09/2003.