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Based on random observation while accompanied by the Director of Engineering, corridor doors are not always positive latching in accordance with 19.3.6.3.2 and/or that corridor doors are not installed to maintain a smoke tight condition. Failure to maintain corridor doors in accordance with NFPA 101 could allow smoke to spread from room to room in a fire emergency

Findings include:

A. 08/07/13 11:00am, corridor doors contain a push/pull along with separate deadbolt hardware. These corridor doors do not comply with 19.3.6.3.2 and 7.2.1.5 for containing positive latching hardware. Example locations observed:

1. Nursery-2nd floor
2. O.R. # 2 and O.R. # 3 - 1st floor


B. 08/07/2013 at 2:50 pm, 1st floor means of egress corridor doors from the Surgery rooms A and B do not comply with 19.3.6.3.2. Due to the following:

1. No obvious latching hardware to comply with 7.2.1.5.

Based on random observation during the survey walk-through while accompanied by the Director of Engineering, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the exit access corridor during a fire emergency.

Findings include:

A. 08//08/2013 at 10:00 am, various rooms which do not meet the minimum requirements for hazardous areas are being used as storage rooms and deemed hazardous due to the amount of combustible materials boxes, files, equipment and furniture. These rooms/areas do not comply with 19.3.2.1 for protection of hazardous areas due to the following:

1. 1st floor Surgery O.R. # 3 is being used as storage and does not comply with 19.3.2.1 due to the following:
a. Two entry doors, one from the means of egress corridor and the other to substerile are not self closing.
b. The door to substerile lacks latching hardware.

2. 1st floor Surgery Support area (as designated on the facility Life Safety floor plan) is deemed as a storage area greater than 50 square feet with shelving along all walls containing combustible materials. This area does not comply with 19.3.2 and 8.4 due to the lack of a smoke tight separation between this area and the means of egress corridor.

3. 08/08/2013 at 11:05 am Ground floor elevator equipment room adjacent to Gift Shop storage contains materials stored within the room unrelated to the elevator equipment.

4. 08/07/2013 at 9:55am 3rd floor HVAC shaft from Mechanical roof top air handling unit contains a gurney being stored within the duct shaft from the rooftop HVAC unit. The third floor maintenance landing within the shaft is being used for storage which does not comply with 19.3.2.

5. 08/07/2013 at 9:50am roof top HVAC unit contains boxes of material stored within the unit and open to the vertical shaft which does not comply with 19.3.2. The roof top enclosure is deemed as being the HVAC unit due to the ability to walk directly into the air handling unit enclosure from the roof. This is not a mechanical penthouse, therefore materials of any type may not be stored within an air handling unit.

6. 08/07/13 at 9:53am 3rd floor Dirty Linen storage (sprinklered and formerly a shower room) located adjacent to the classroom lacks separation from the means of egress corridor due to a door which is not self closing.


B. 08/08/2013 at 10:30am Ground floor Corridor entry doors from hazardous areas contains a delay operated self closing device which does not appear to operate properly to comply with 19.3.6.2. Both door closer's contain a delayed closing sequence which exceeds that allowed by 7.2.1.4.5 for the timing allowed through the use of pounds of force applied. Both doors far exceeded 30 seconds to latch.

1. Dirty Linen room adjacent to the South exit stair
2. Housekeeping room adjacent to the South exit stair

C. 08/08/13 at 9:15am 1st floor Technology closet (sprinklered) located adjacent to Central Sterile Processing/Receiving contains a broken ceiling tile which does not provide a smoke tight enclosure.

D. 08/08/13 at 9:25am 1st floor Central Sterile Processing/Receiving contains an entry door frame which lacks the following:

1. A fire rated label to indicate the fire resistance of the frame.
2. Maintaining the fire resistance of the frame due to a large hole within the frame where the U.L. listed latch strike plate should be.

E. 08/07/13 at 10:00am 3rd floor Respiratory Storage lacks separation from the means of egress corridor due to a door which is not self closing.

F. 08/08/13 at 11:20am 1960's building The Boiler Electrical Room contains a corridor door which is not indicated to be a labeled fire resistant door.

Based on random observation and staff interview during the survey walk-through, while accompanied by the Director of Engineering, not all exit or exit access doors are arranged so that exits are readily accessible at all times to comply with 19.2.1 and Chapter 7. These deficiencies could affect all patients, staff and visitors in the facility, by preventing occupants from reaching an exit from the building.

Findings include:

A. 08/08/2013 at 10:15 East West corridor (from the ED to Nuclear Medicine) adjacent to the Radiology suite contains an exit sign directing the means of egress through the Radiology suite which is an intervening room. This condition does not comply with 19.2.5.9.


B. 08/08/2013 at 8:45am Exit access is not readily accessible at all times to comply with 7.1. Means of egress corridors contain doors having delayed egress hardware which does not comply with 7.2.1.6 due to the following:

1. Signage is not available on any of the delayed egress doors in order to comply with 7.2.1.6.1(d). Locations observed include:
a. 1st floor South exit from the Emergency Department
b. 2nd floor means of egress into MOB
c. 2nd floor Stair exit (Stair adjacent to MOB)
d. 2nd floor Stair adjacent to C-Section

2. The delayed egress mechanism does not comply with 7.2.1.6.1(a). During the test of the fire alarm system the delayed egress feature continued to operate. This was observed at the 3rd floor exit into the MOB. Surveyor was informed that the remainder of the delayed egress doors have the same condition.

C. 08/07/13 at 9:45am, the rooftop egress path for the Elevator Lobby serving the Helipad was observed to not be in compliance with Chapter 7, based on the following observed conditions:

1. The egress path was observed to cross from a steel landing to a steel ramp to the Helipad, and then down wooden steps to the roof. However, the only means into the building is from the elevated steel landing.
a. The wooden steps do not comply with the use of limited combustible materials to be used on a roof of less than 2-hour fire rating.

b. The path of egress does not allow for reentry into the building from the roof due to the steel landing's lack of a second means of egress. A steel channel along the edge of the landing was observed which protrudes above the elevated landing by more than 3". The total change in elevation above the roof at the landing level does not comply with 7.1.6.2.and 7.2.2.2.1(b).
c. The landing was observed to lack a handrail to comply 7.2.2.4.2.

2. The egress path along the roof from the wooden steps along side the helipad was observed to be in close proximity to the roof edge, contains tripping hazards(elevated steel support beams for the helipad) and lacks a handrail to comply with 7.2.2.4.2.

D. 08/07/13 at 2:15pm 1st floor MOB building Outpatient Cardiac Rehab means of egress corridor does not have two exits. The center means of egress corridor passes through a waiting room and a Physical Therapy room which does not comply with 19.2.5.9 for intervening rooms.

Based on document review, while accompanied by the Director of Engineering, the facility's emergency lighting is not inspected, tested, and maintained in accordance with 7.9. This deficiency could affect any patients, staff, or visitors in the building because emergency lighting components may not be operational.

Findings include:

A. 08/07/13 at 9:40am Through document review, it was determined that the facility does not test the emergency lighting system components on an annual basis to comply with 7.9.3. During the review of records, it was determined that no records were available for the annual 90 minute test for all battery powered lights.
.

Based on random observation during the survey walk-through, while accompanied by the Director of Engineering, not all portions of the building fire alarm system are installed to comply with 19.3.4. This could effect all building occupants if the fire alarm system does not operate properly during a fire emergency.

Findings include:

A. 08/08/13, at 1:30pm 1st floor corridor adjacent to Lab- during the activation of the fire alarm system a pair of cross corridor doors within a designated means of egress caught on the finished flooring and therefore did not close upon activation.

Based on document review, while accompanied by the Director of Engineering, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6. This deficiency could affect any patients, staff, or visitors in the building because fire alarm system components may not be operational.

Findings include:

A. 08/07/13 at 8:50am Through document review, it was determined that the facility does not test fire alarm system components on a periodic basis to comply with NFPA 72 1999 Table 7-3.2. During the review of records , it was determined that no records were available for the quarterly inspection of the fire alarm system.

B. 08/07/13 at 9:30am Through document review, it was determined that the facility does not test fire alarm system components on an annual basis to comply with NFPA 72 1999 7-9.3. During the review of records, it was determined that no records were available for the annual 90 minute test for all battery powered lights.
.

Based on random observation during the survey walk through, while accompanied by the Director of Engineering, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. This deficient practice may compromise the prompt care and movement of occupants during a fire/smoke emergency.

A. 08/07/2013 at 3:00 pm ,2nd floor, OB Wing C-Section corridor contains a desk, shelving and combustible materials stored within the means of egress directly leading to the exit stair

B. 08/07/13 at 11:10am 1st floor MOB building, outpatient Cardiac Rehabilitation means of egress corridor contains desks, coat racks, shelves and numerous objects which reduce the required width of the corridor.

C. 08/07/13 at 1:10pm 1st floor Surgery means of egress corridor contains stools, shelves and numerous objects which reduce the required width of the corridor.

Based on random observation during the survey walk-through while accompanied by the Director of Engineering, not all piped-in medical gas systems are installed and maintained in accordance with NFPA 99.

Findings include:

A. 08/07/13 at 3:10 pm Manual medical gas shutoff (zone) valves were observed within the same room as the station outlets they serve, this does not comply with NFPA 99 1999 Location observed:

1. Third floor, Endoscopy recovery

Based on random observation during the survey walk-through, while accompanied by the Director of Engineering, electrical wiring and equipment was not installed and maintained in accordance with NFPA 70 National Electric Code and NFPA 101, 9.1.2. This deficiency could result in exposure of occupants to electrical shock.


A. 08/07/13 at 12:40pm Emergency power electrical receptacles are not labeled to identify the circuit and panel from which they are fed to comply with NFPA 70-1999, 517-19 a. This condition was observed throughout critical care areas of the facility. Example locations include:

1. 1st floor Operating room #2
2. 1st floor Operating room #3
3. 2nd floor Delivery rooms (C-Section)
4. 2nd floor LDR rooms


B. 08/07/13, 12:40 pm, Electrical panel "C" located in the Surgery corridor indicated to serve outlets in Recovery room refers to Distrubution panel "LMB" the one line diagram refers to transfer switch #4, however, if this is the transfer switch for the "critical branch" service the transfer switch appears to serve the laundry area, both boiler units, the ED corridor and other areas. The transfer switch is considered to be carrying a mixed load and not solely the critical branch. The separation of the three service branches Life Safety, Critical and Equipment is not complete

Based on random observation during the survey walk-through, document review, and staff interview, while accompanied by the Director of Engineering, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

The finding is:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.


B. 08/07/13 at 2:45pm By direct observation the surveyor finds that the following condition is not met A725: CFR 482.41?(3) The extent and complexity of facilities must be determined by the services offered. Physical facilities must be large enough, numerous enough, appropriately designed and equipped, and of appropriate complexity to provide the services offered in accordance with Federal and State laws, regulations and guidelines and accepted standards of practice for that location or service. Surveyor observed the following:
1. 2nd floor O.B. unit lacks much of what meets minimum state requirements:
a. LDR rooms lack the appropriate ceiling tile.
b. LDR rooms lack the appropriate wall base.
c. LDR rooms contain wall decorations such as dried floral wreath arrangements which cannot be adequately cleaned to maintain the proper environment.
d. Patient rooms 215, 217 and 219 contained bathrooms with showers. The showers lacked access to a nurse call pull chord due to the distant location of the available chord (at toilet).

Based on random observation during the survey walk-through, while accompanied by the Director of Engineering, electrical wiring and equipment was not installed and maintained in accordance with NFPA 70 National Electric Code and NFPA 101, 9.1.2. This deficiency could result in exposure of occupants to electrical shock.

Finding is:

A. 08/07/13 at 1:00 pm Through direct observation normal power receptacles were not provided in the following locations to comply with NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1:

1. 1st floor Operating room #2
2. 1st floor Operating room # 3
3. 1st floor Stage I Recovery room
4. 2nd C-Section
5. 2nd floor LDR rooms

Based on random observation while accompanied by the Director of Engineering, corridor doors are not always positive latching in accordance with 19.3.6.3.2 and/or that corridor doors are not installed to maintain a smoke tight condition. Failure to maintain corridor doors in accordance with NFPA 101 could allow smoke to spread from room to room in a fire emergency

Findings include:

A. 08/07/13 11:00am, corridor doors contain a push/pull along with separate deadbolt hardware. These corridor doors do not comply with 19.3.6.3.2 and 7.2.1.5 for containing positive latching hardware. Example locations observed:

1. Nursery-2nd floor
2. O.R. # 2 and O.R. # 3 - 1st floor


B. 08/07/2013 at 2:50 pm, 1st floor means of egress corridor doors from the Surgery rooms A and B do not comply with 19.3.6.3.2. Due to the following:

1. No obvious latching hardware to comply with 7.2.1.5.

Based on random observation during the survey walk-through while accompanied by the Director of Engineering, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and 8.4.1. These deficiencies could affect all patients, staff and visitors within the smoke compartment, by allowing smoke and fire to escape from hazardous rooms into the exit access corridor during a fire emergency.

Findings include:

A. 08//08/2013 at 10:00 am, various rooms which do not meet the minimum requirements for hazardous areas are being used as storage rooms and deemed hazardous due to the amount of combustible materials boxes, files, equipment and furniture. These rooms/areas do not comply with 19.3.2.1 for protection of hazardous areas due to the following:

1. 1st floor Surgery O.R. # 3 is being used as storage and does not comply with 19.3.2.1 due to the following:
a. Two entry doors, one from the means of egress corridor and the other to substerile are not self closing.
b. The door to substerile lacks latching hardware.

2. 1st floor Surgery Support area (as designated on the facility Life Safety floor plan) is deemed as a storage area greater than 50 square feet with shelving along all walls containing combustible materials. This area does not comply with 19.3.2 and 8.4 due to the lack of a smoke tight separation between this area and the means of egress corridor.

3. 08/08/2013 at 11:05 am Ground floor elevator equipment room adjacent to Gift Shop storage contains materials stored within the room unrelated to the elevator equipment.

4. 08/07/2013 at 9:55am 3rd floor HVAC shaft from Mechanical roof top air handling unit contains a gurney being stored within the duct shaft from the rooftop HVAC unit. The third floor maintenance landing within the shaft is being used for storage which does not comply with 19.3.2.

5. 08/07/2013 at 9:50am roof top HVAC unit contains boxes of material stored within the unit and open to the vertical shaft which does not comply with 19.3.2. The roof top enclosure is deemed as being the HVAC unit due to the ability to walk directly into the air handling unit enclosure from the roof. This is not a mechanical penthouse, therefore materials of any type may not be stored within an air handling unit.

6. 08/07/13 at 9:53am 3rd floor Dirty Linen storage (sprinklered and formerly a shower room) located adjacent to the classroom lacks separation from the means of egress corridor due to a door which is not self closing.


B. 08/08/2013 at 10:30am Ground floor Corridor entry doors from hazardous areas contains a delay operated self closing device which does not appear to operate properly to comply with 19.3.6.2. Both door closer's contain a delayed closing sequence which exceeds that allowed by 7.2.1.4.5 for the timing allowed through the use of pounds of force applied. Both doors far exceeded 30 seconds to latch.

1. Dirty Linen room adjacent to the South exit stair
2. Housekeeping room adjacent to the South exit stair

C. 08/08/13 at 9:15am 1st floor Technology closet (sprinklered) located adjacent to Central Sterile Processing/Receiving contains a broken ceiling tile which does not provide a smoke tight enclosure.

D. 08/08/13 at 9:25am 1st floor Central Sterile Processing/Receiving contains an entry door frame which lacks the following:

1. A fire rated label to indicate the fire resistance of the frame.
2. Maintaining the fire resistance of the frame due to a large hole within the frame where the U.L. listed latch strike plate should be.

E. 08/07/13 at 10:00am 3rd floor Respiratory Storage lacks separation from the means of egress corridor due to a door which is not self closing.

F. 08/08/13 at 11:20am 1960's building The Boiler Electrical Room contains a corridor door which is not indicated to be a labeled fire resistant door.

Based on random observation and staff interview during the survey walk-through, while accompanied by the Director of Engineering, not all exit or exit access doors are arranged so that exits are readily accessible at all times to comply with 19.2.1 and Chapter 7. These deficiencies could affect all patients, staff and visitors in the facility, by preventing occupants from reaching an exit from the building.

Findings include:

A. 08/08/2013 at 10:15 East West corridor (from the ED to Nuclear Medicine) adjacent to the Radiology suite contains an exit sign directing the means of egress through the Radiology suite which is an intervening room. This condition does not comply with 19.2.5.9.


B. 08/08/2013 at 8:45am Exit access is not readily accessible at all times to comply with 7.1. Means of egress corridors contain doors having delayed egress hardware which does not comply with 7.2.1.6 due to the following:

1. Signage is not available on any of the delayed egress doors in order to comply with 7.2.1.6.1(d). Locations observed include:
a. 1st floor South exit from the Emergency Department
b. 2nd floor means of egress into MOB
c. 2nd floor Stair exit (Stair adjacent to MOB)
d. 2nd floor Stair adjacent to C-Section

2. The delayed egress mechanism does not comply with 7.2.1.6.1(a). During the test of the fire alarm system the delayed egress feature continued to operate. This was observed at the 3rd floor exit into the MOB. Surveyor was informed that the remainder of the delayed egress doors have the same condition.

C. 08/07/13 at 9:45am, the rooftop egress path for the Elevator Lobby serving the Helipad was observed to not be in compliance with Chapter 7, based on the following observed conditions:

1. The egress path was observed to cross from a steel landing to a steel ramp to the Helipad, and then down wooden steps to the roof. However, the only means into the building is from the elevated steel landing.
a. The wooden steps do not comply with the use of limited combustible materials to be used on a roof of less than 2-hour fire rating.

b. The path of egress does not allow for reentry into the building from the roof due to the steel landing's lack of a second means of egress. A steel channel along the edge of the landing was observed which protrudes above the elevated landing by more than 3". The total change in elevation above the roof at the landing level does not comply with 7.1.6.2.and 7.2.2.2.1(b).
c. The landing was observed to lack a handrail to comply 7.2.2.4.2.

2. The egress path along the roof from the wooden steps along side the helipad was observed to be in close proximity to the roof edge, contains tripping hazards(elevated steel support beams for the helipad) and lacks a handrail to comply with 7.2.2.4.2.

D. 08/07/13 at 2:15pm 1st floor MOB building Outpatient Cardiac Rehab means of egress corridor does not have two exits. The center means of egress corridor passes through a waiting room and a Physical Therapy room which does not comply with 19.2.5.9 for intervening rooms.

Based on document review, while accompanied by the Director of Engineering, the facility's emergency lighting is not inspected, tested, and maintained in accordance with 7.9. This deficiency could affect any patients, staff, or visitors in the building because emergency lighting components may not be operational.

Findings include:

A. 08/07/13 at 9:40am Through document review, it was determined that the facility does not test the emergency lighting system components on an annual basis to comply with 7.9.3. During the review of records, it was determined that no records were available for the annual 90 minute test for all battery powered lights.
.

Based on random observation during the survey walk-through, while accompanied by the Director of Engineering, not all portions of the building fire alarm system are installed to comply with 19.3.4. This could effect all building occupants if the fire alarm system does not operate properly during a fire emergency.

Findings include:

A. 08/08/13, at 1:30pm 1st floor corridor adjacent to Lab- during the activation of the fire alarm system a pair of cross corridor doors within a designated means of egress caught on the finished flooring and therefore did not close upon activation.

Based on document review, while accompanied by the Director of Engineering, the facility's fire alarm system is not inspected, tested, and maintained in accordance with 9.6. This deficiency could affect any patients, staff, or visitors in the building because fire alarm system components may not be operational.

Findings include:

A. 08/07/13 at 8:50am Through document review, it was determined that the facility does not test fire alarm system components on a periodic basis to comply with NFPA 72 1999 Table 7-3.2. During the review of records , it was determined that no records were available for the quarterly inspection of the fire alarm system.

B. 08/07/13 at 9:30am Through document review, it was determined that the facility does not test fire alarm system components on an annual basis to comply with NFPA 72 1999 7-9.3. During the review of records, it was determined that no records were available for the annual 90 minute test for all battery powered lights.
.

Based on random observation during the survey walk through, while accompanied by the Director of Engineering, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency to comply with 19.2.3.3. This deficient practice may compromise the prompt care and movement of occupants during a fire/smoke emergency.

A. 08/07/2013 at 3:00 pm ,2nd floor, OB Wing C-Section corridor contains a desk, shelving and combustible materials stored within the means of egress directly leading to the exit stair

B. 08/07/13 at 11:10am 1st floor MOB building, outpatient Cardiac Rehabilitation means of egress corridor contains desks, coat racks, shelves and numerous objects which reduce the required width of the corridor.

C. 08/07/13 at 1:10pm 1st floor Surgery means of egress corridor contains stools, shelves and numerous objects which reduce the required width of the corridor.

Based on random observation during the survey walk-through while accompanied by the Director of Engineering, not all piped-in medical gas systems are installed and maintained in accordance with NFPA 99.

Findings include:

A. 08/07/13 at 3:10 pm Manual medical gas shutoff (zone) valves were observed within the same room as the station outlets they serve, this does not comply with NFPA 99 1999 Location observed:

1. Third floor, Endoscopy recovery

Based on random observation during the survey walk-through, while accompanied by the Director of Engineering, electrical wiring and equipment was not installed and maintained in accordance with NFPA 70 National Electric Code and NFPA 101, 9.1.2. This deficiency could result in exposure of occupants to electrical shock.


A. 08/07/13 at 12:40pm Emergency power electrical receptacles are not labeled to identify the circuit and panel from which they are fed to comply with NFPA 70-1999, 517-19 a. This condition was observed throughout critical care areas of the facility. Example locations include:

1. 1st floor Operating room #2
2. 1st floor Operating room #3
3. 2nd floor Delivery rooms (C-Section)
4. 2nd floor LDR rooms


B. 08/07/13, 12:40 pm, Electrical panel "C" located in the Surgery corridor indicated to serve outlets in Recovery room refers to Distrubution panel "LMB" the one line diagram refers to transfer switch #4, however, if this is the transfer switch for the "critical branch" service the transfer switch appears to serve the laundry area, both boiler units, the ED corridor and other areas. The transfer switch is considered to be carrying a mixed load and not solely the critical branch. The separation of the three service branches Life Safety, Critical and Equipment is not complete

Based on random observation during the survey walk-through, document review, and staff interview, while accompanied by the Director of Engineering, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

The finding is:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.


B. 08/07/13 at 2:45pm By direct observation the surveyor finds that the following condition is not met A725: CFR 482.41?(3) The extent and complexity of facilities must be determined by the services offered. Physical facilities must be large enough, numerous enough, appropriately designed and equipped, and of appropriate complexity to provide the services offered in accordance with Federal and State laws, regulations and guidelines and accepted standards of practice for that location or service. Surveyor observed the following:
1. 2nd floor O.B. unit lacks much of what meets minimum state requirements:
a. LDR rooms lack the appropriate ceiling tile.
b. LDR rooms lack the appropriate wall base.
c. LDR rooms contain wall decorations such as dried floral wreath arrangements which cannot be adequately cleaned to maintain the proper environment.
d. Patient rooms 215, 217 and 219 contained bathrooms with showers. The showers lacked access to a nurse call pull chord due to the distant location of the available chord (at toilet).

Based on random observation during the survey walk-through, while accompanied by the Director of Engineering, electrical wiring and equipment was not installed and maintained in accordance with NFPA 70 National Electric Code and NFPA 101, 9.1.2. This deficiency could result in exposure of occupants to electrical shock.

Finding is:

A. 08/07/13 at 1:00 pm Through direct observation normal power receptacles were not provided in the following locations to comply with NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1:

1. 1st floor Operating room #2
2. 1st floor Operating room # 3
3. 1st floor Stage I Recovery room
4. 2nd C-Section
5. 2nd floor LDR rooms