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It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the building construction as required. This was evidenced by the following:

1. Building structure protective assemblies were not maintained, as follows:
A) Sections of unprotected steel beams and steel columns were observed throughout the building on each floor where the protective spray-on fire proofing was removed.

Life Safety Code Section 19.1.6.2 outlines allowed construction types. The original building is classified as Type I (332) which must be maintained and not diminished.

2. The cross corridors in the one-hour fire wall at the dining room were warped and failed to close together.

3. The fire command center failed to be of one-hour fire construction with 3/4-hour fire rated, self-closing doors.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the smoke resistance rating of the corridor walls as required. This was evidenced by the following:

1. There was a window opening through the corridor wall at the kitchen dishwashing area which failed to maintain the smoke resistant rating of the corridor walls.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the doors that protect the corridors as required by 19.3.6.3. This was evidenced by the following:

1. The doors to the existing Operating Room (OR) room and the second floor C-section OR failed to allow closing when the push-to-open device was activated. The doors were programmed to remain in the open position for a set period of time and could not be closed while the system was activated.

2. The doors to ICU 5 and 8 on the second floor in the West Wing failed to close and latch into the frames.

3. The door to the servery area from the kitchen failed to be equipped with latching hardware. The servery area was open to the egress corridor and corridor doors shall be equipped with latching hardware.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the hazardous areas as required. This was evidenced by the following:

1. The facility failed to maintain the storage areas on the third floor. There was combustible storage located outside the storage room in the mechanical, air handler area. The third floor does not meet the exit requirements for the entire area third floor area to be classified as Storage. Combustible storage shall be limited to the combustible storage room located on the third floor. Storage in the mechanical area included, but was not limited to, cartons and cases of combustible items on pallets and carts.

2. The facility failed to install positive latching devices on the secondary door of the double doors to the third floor storage room. The leaf door must positively latch into the doorframe assembly when the door is opened and released.

3. The second floor clean storage room in the Peak Care Unit failed to have self-closing, 3/4-hour fire rated doors.

4. The second floor West wing equipment storage room failed to be equipped with a self-closing, 3/4-hour fire rated door.

5. The self-closing, 60-minute fire rated secondary door (leaf door) to the facility management area was split at the top and bottom latching areas and failed to maintain the fire resistant rating of the door and the door failed to positively latch into the doorframe assembly. This door cannot be repaired unless the fire resistant rating is re-evaluated by an approved testing facility.

6. The double, fire rated doors to the material management area and the electrical room in the ED were split at the top and bottom at the latching area and the doors need to be replaced. The secondary leaf doors also need to be equipped with positive latching hardware.

7. The single door to the corridor from the material management area failed to have a fire resistant rating of 3/4-hour.

8. The ED clean storage room which exceeded 100 sq. ft. failed to have one-hour fire construction and 3/4-hour, self-closing fire rated doors.

9. One of three doors to the first floor record storage room failed to have a 3/4-hour fire rating.

10. The kitchen storage room which exceeded 100 sq. ft. failed to have one-hour fire construction and equipped with a 3/4-hour fire rated self-closing door.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, the facility failed to maintain the stair handrails in accordance with NFPA 7.2. This was evidenced by the following:

1. The facility failed to install handrails on the steps on the third floor lobby area to the chiller area, and at two (2) locations in the chiller area.

NFPA 101
7.2.2.4.2* Handrails.
Stairs and ramps shall have handrails on both sides. In addition, handrails shall be provided within 30 in. (76 cm) of all portions of the required egress width of stairs. The required egress width shall be provided along the natural path of travel. (See also 7.2.2.4.5.)

7.2.2.4.5* Handrail Details.
(1) Handrails on stairs shall be not less than 34 in. (86 cm) and not more than 38 in. (96 cm) above the surface of the tread, measured vertically to the top of the rail from the leading edge of the tread.

Exception No. 1: The height of required handrails that form part of a guard shall be permitted to exceed 38 in. (96 cm) but shall not exceed 42 in. (107 cm), measured vertically to the top of the rail from the leading edge of the tread.

Exception No. 2: Existing required handrails shall be permitted to be not less than 30 in. (76 cm) and not more than 38 in. (96 cm) above the upper surface of the tread, measured vertically to the top of the rail from the leading edge of the tread.

Exception No. 3*: Additional handrails that are lower or higher than the main handrail shall be permitted.
(2) * New handrails shall provide a clearance of not less than 1 1/2 in. (3.8 cm) between the handrail and the wall to which it is fastened.
(3) * Handrails shall have a circular cross section with an outside diameter of not less than 1 1/4 in. (3.2 cm) and not more than 2 in. (5 cm).

Exception: Any other shape with a perimeter dimension of not less than 4 in. (10.2 cm), but not more than 6 1/4 in. (15.9 cm), and with the largest cross-sectional dimension not more than 2 1/4 in. (5.7 cm) shall be permitted, provided that edges are rounded so as to provide a radius of not less than 1/8 in. (0.3 cm).
(4) New handrails shall be continuously graspable along their entire length.

Exception: Handrail brackets or balusters attached to the bottom surface of the handrail shall not be considered to be obstructions to graspability, provided that the following criteria are met:
(a) They do not project horizontally beyond the sides of the handrail within 1 1/2 in. (3.75 cm) of the bottom of the handrail and provided that, for each 1/2 in. (1.3 cm) of additional handrail perimeter dimension above 4 in. (10 cm), the vertical clearance dimension of 1 1/2 in. (3.75 cm) can be reduced by 1/8 in. (0.3 cm).
(b) They have edges with a radius of not less than 1/8 in. (0.3 cm).
(c) They obstruct not in excess of 20 percent of the handrail length.
(5) New handrail ends shall be returned to the wall or floor or shall terminate at newel posts.
(6) New handrails that are not continuous between flights shall extend horizontally, at the required height, not less than 12 in. (30.5 cm) beyond the top riser and continue to slope for a depth of one tread beyond the bottom riser.

Exception: Within dwelling units the handrail shall be permitted to extend, at the required height, to points directly above the top and bottom risers.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the exit corridors as required by 18.2.5.10. This was evidenced by the following:

1. The facility failed to maintain the corridors without dead ends greater than 30 feet in length. The corridor near the dining room extending to the two-hour fire wall exceeded 30 feet in length when the doors equipped with electro-magnetic devices were locked. The corridor was measured at 35 feet.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the exit directional signs as required. This was evidenced by the following:

1. The facility failed to install an exit signs above the cross corridor doors into the dining room corridor near the Chapel; and at the junction of the main corridor and the educational corridor.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the fire alarm system as required. This was evidenced by the following:

1. The facility failed to have the smoke detectors on the third floor installed in accordance with NFPA 72. The smoke detector for the elevator was mounted on the bottom edge of the structural beam and not in the beam pocket.

2-3.4.6.1 Flat Ceilings.
For ceiling heights of 12 ft (3.66 m) or lower, and beam or solid joist depths of 1 ft (0.3 m) or less, smooth ceiling spaces running in the direction parallel to the run of the beams or solid joists shall be used and one-half the smooth ceiling spacing shall be in the direction perpendicular to the run of the beams or solid joists. For beams over 1 ft (0.3 m) in depth, spot-type detectors shall be permitted to be located either on the ceiling or on the bottom of the beams.

For beam depths exceeding 1 ft (0.3 m) or for ceiling heights exceeding 12 ft (3.66 m), spot-type detectors shall be located on the ceiling in every beam pocket.

2. The smoke detectors located on the second floor in the Peak Care Unit failed have the proper coverage spacing. The corridors were equipped with drop down panels greater than 12 inches at ceiling level which created pockets and areas unprotected.

3. There were ceiling pockets without smoke detectors located in the second floor West wing corridor near the nourishment room and the first floor corridor near the chapel.

4. The second floor West wing nourishment room was open to the corridor and failed to be equipped with a smoke detector.

18.3.6.1 Corridors shall be separated from all other areas by partitions complying with 18.3.6.2 through 18.3.6.5. (See also 18.2.5.9.)

Exception No. 1: Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met:
(a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.
(d) The space does not obstruct access to required exits.

5. The facility failed to install smoke detectors in OR1 and the C-Section OR.

6. The front cross corridor doors to the second floor Peak Care Unit failed to release from the electro-magnetic hold open devices when the fire alarm system was tested.

7. The heat detector in the elevator equipment room on the first floor failed to be located within two feet of the fire sprinkler head to shut down power to the elevator prior to sprinkler activation.
3-9.4.2 If heat detectors are used to shut down elevator power prior to sprinkler operation, they shall be placed within 2 ft (610 mm) of each sprinkler head and be installed in accordance with the requirements of Chapter 2.

It was determined by observation or record review during the course of the survey on January 4-7, 2011 that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems and NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

1. The fire sprinkler heads located in the kitchen were loaded with foreign matter and need to be replaced.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the smoking regulations as required. This was evidenced by the following:

1. The facility failed to provide ashtrays of non-combustible materials and of safe design at the entrance to the building. The campus is non-smoking; however, there were cigarette butts observed in the downspout near the front entrance doors.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the cooking facility in accordance with 9.2.3, 19.3.2.6, NFPA 96. This was evidenced by the following:

1. The kitchen appliances were not located under the hood and aligned with the nozzles of the fixed fire suppression system. (staff relocated the appliances during the survey)

NFPA Standard 96 Section 9-1.2.2 requires that cooking appliances requiring protection not be moved, modified, or rearranged without prior reevaluation of the fire-extinguishing system by the system installer or servicing agent, unless otherwise allowed by the design of the fire-extinguishing system. Exception: Cooking appliances moved to perform maintenance and cleaning provided the appliances are returned to their original positioning prior to cooking operations.

NFPA 96 Section 9-1.2.3: All deep fat fryers shall be installed with at least a 16-inch space between the fryer and surface flames from adjacent cooking equipment. Exception: Where a steel or tempered glass baffle plate is installed at a minimum 8 inches in height between the fryer and surface flames of the adjacent appliance.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the egress corridors as required. This was evidenced by the following:

1. The facility failed to maintain the egress corridor at the dining room. There were vending machines located in the corridor obstructing the clear width of the exit pathway.

2. The facility failed to maintain the egress from the first floor ED staff lounge. The walk was covered with snow and ice.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, the facility failed to maintain the medical gas storage area in accordance with NFPA 99. This was evidenced by the following:

1. The electrical outlets and switches were not maintained at a level of 5-feet above the floor surface in the medical gas storage area on the third floor.

NFPA-99, section 4-5.1.1.2 requires; "Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 5 ft (152 cm) above the floor as a precaution against their physical damage."

It was determined by observation, record review and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to install and maintain the environmental systems in the anesthetizing locations in accordance with NFPA 99. This was evidenced by the following:

1. A review of the facility's records failed to document the mechanical ventilation system supplying the anesthetizing locations had maintained a humidity level of 35% or greater in the existing OR1, newly opened OR3, or in the C-section OR.

During the walk-through inspection on January 5, 2011; the C-section OR humidity was observed at 21.9 % with a temperature of 60 degrees. At 09:30 on January 6, 2011, the humidity level was at 23.8%. Paperwork indicated humidity in the C-section OR was trending at approximately 20-25%.

Paperwork indicated humidity in OR1 was between 2 % and 9% between 16:00 January 3, 2011 and 15:00 January 4, 2011. Paperwork further indicated the humidity levels at approximately 5% during September, October, November, December 2010; and January and February 1011.

Paperwork indicated humidity in OR3 was 15% at 21:00 on January 4, 2011; 12% at 08:00 January 6, 2011.

NFPA 99 Section 5-4.1.1 requires that the mechanical ventilation system supplying anesthetizing locations have the capability of controlling relative humidity at a level of 35% or greater.

2. The ventilating system serving anesthetizing locations was not installed in accordance with NFPA 99 Section 5-4.1.2 and 5-4.1.3, as required. There was no smoke evacuation system installed in the existing OR1 and in the C-Section OR.

NFPA 99 Section 5-4.1.2: Supply and exhaust systems for anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. Section 5-4.1.3: Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011 that the facility failed to maintain the electrical system in accordance with National Electrical Codes. This was evidenced by the following:

1. The facility failed to maintain a minimum of 3 feet of clearance around the electrical panels located on the third floor.

2. The electrical wiring failed to be terminated in the junction box and the approved coverplate was missing from the electrical wiring junction box located above the ceiling tiles at the cross corridor doors to the Peak Care Unit (surgery unit).

3. The wiring junction box on the fire sprinkler riser in the first floor riser room failed to have an approved cover.

4. There was an extension cord attached to the wall and being used for permanent wiring in the first floor riser room to supply power to water meter box.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the building construction as required. This was evidenced by the following:

1. Building structure protective assemblies were not maintained, as follows:
A) Sections of unprotected steel beams and steel columns were observed throughout the building on each floor where the protective spray-on fire proofing was removed.

Life Safety Code Section 19.1.6.2 outlines allowed construction types. The original building is classified as Type I (332) which must be maintained and not diminished.

2. The cross corridors in the one-hour fire wall at the dining room were warped and failed to close together.

3. The fire command center failed to be of one-hour fire construction with 3/4-hour fire rated, self-closing doors.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the smoke resistance rating of the corridor walls as required. This was evidenced by the following:

1. There was a window opening through the corridor wall at the kitchen dishwashing area which failed to maintain the smoke resistant rating of the corridor walls.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the doors that protect the corridors as required by 19.3.6.3. This was evidenced by the following:

1. The doors to the existing Operating Room (OR) room and the second floor C-section OR failed to allow closing when the push-to-open device was activated. The doors were programmed to remain in the open position for a set period of time and could not be closed while the system was activated.

2. The doors to ICU 5 and 8 on the second floor in the West Wing failed to close and latch into the frames.

3. The door to the servery area from the kitchen failed to be equipped with latching hardware. The servery area was open to the egress corridor and corridor doors shall be equipped with latching hardware.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the hazardous areas as required. This was evidenced by the following:

1. The facility failed to maintain the storage areas on the third floor. There was combustible storage located outside the storage room in the mechanical, air handler area. The third floor does not meet the exit requirements for the entire area third floor area to be classified as Storage. Combustible storage shall be limited to the combustible storage room located on the third floor. Storage in the mechanical area included, but was not limited to, cartons and cases of combustible items on pallets and carts.

2. The facility failed to install positive latching devices on the secondary door of the double doors to the third floor storage room. The leaf door must positively latch into the doorframe assembly when the door is opened and released.

3. The second floor clean storage room in the Peak Care Unit failed to have self-closing, 3/4-hour fire rated doors.

4. The second floor West wing equipment storage room failed to be equipped with a self-closing, 3/4-hour fire rated door.

5. The self-closing, 60-minute fire rated secondary door (leaf door) to the facility management area was split at the top and bottom latching areas and failed to maintain the fire resistant rating of the door and the door failed to positively latch into the doorframe assembly. This door cannot be repaired unless the fire resistant rating is re-evaluated by an approved testing facility.

6. The double, fire rated doors to the material management area and the electrical room in the ED were split at the top and bottom at the latching area and the doors need to be replaced. The secondary leaf doors also need to be equipped with positive latching hardware.

7. The single door to the corridor from the material management area failed to have a fire resistant rating of 3/4-hour.

8. The ED clean storage room which exceeded 100 sq. ft. failed to have one-hour fire construction and 3/4-hour, self-closing fire rated doors.

9. One of three doors to the first floor record storage room failed to have a 3/4-hour fire rating.

10. The kitchen storage room which exceeded 100 sq. ft. failed to have one-hour fire construction and equipped with a 3/4-hour fire rated self-closing door.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, the facility failed to maintain the stair handrails in accordance with NFPA 7.2. This was evidenced by the following:

1. The facility failed to install handrails on the steps on the third floor lobby area to the chiller area, and at two (2) locations in the chiller area.

NFPA 101
7.2.2.4.2* Handrails.
Stairs and ramps shall have handrails on both sides. In addition, handrails shall be provided within 30 in. (76 cm) of all portions of the required egress width of stairs. The required egress width shall be provided along the natural path of travel. (See also 7.2.2.4.5.)

7.2.2.4.5* Handrail Details.
(1) Handrails on stairs shall be not less than 34 in. (86 cm) and not more than 38 in. (96 cm) above the surface of the tread, measured vertically to the top of the rail from the leading edge of the tread.

Exception No. 1: The height of required handrails that form part of a guard shall be permitted to exceed 38 in. (96 cm) but shall not exceed 42 in. (107 cm), measured vertically to the top of the rail from the leading edge of the tread.

Exception No. 2: Existing required handrails shall be permitted to be not less than 30 in. (76 cm) and not more than 38 in. (96 cm) above the upper surface of the tread, measured vertically to the top of the rail from the leading edge of the tread.

Exception No. 3*: Additional handrails that are lower or higher than the main handrail shall be permitted.
(2) * New handrails shall provide a clearance of not less than 1 1/2 in. (3.8 cm) between the handrail and the wall to which it is fastened.
(3) * Handrails shall have a circular cross section with an outside diameter of not less than 1 1/4 in. (3.2 cm) and not more than 2 in. (5 cm).

Exception: Any other shape with a perimeter dimension of not less than 4 in. (10.2 cm), but not more than 6 1/4 in. (15.9 cm), and with the largest cross-sectional dimension not more than 2 1/4 in. (5.7 cm) shall be permitted, provided that edges are rounded so as to provide a radius of not less than 1/8 in. (0.3 cm).
(4) New handrails shall be continuously graspable along their entire length.

Exception: Handrail brackets or balusters attached to the bottom surface of the handrail shall not be considered to be obstructions to graspability, provided that the following criteria are met:
(a) They do not project horizontally beyond the sides of the handrail within 1 1/2 in. (3.75 cm) of the bottom of the handrail and provided that, for each 1/2 in. (1.3 cm) of additional handrail perimeter dimension above 4 in. (10 cm), the vertical clearance dimension of 1 1/2 in. (3.75 cm) can be reduced by 1/8 in. (0.3 cm).
(b) They have edges with a radius of not less than 1/8 in. (0.3 cm).
(c) They obstruct not in excess of 20 percent of the handrail length.
(5) New handrail ends shall be returned to the wall or floor or shall terminate at newel posts.
(6) New handrails that are not continuous between flights shall extend horizontally, at the required height, not less than 12 in. (30.5 cm) beyond the top riser and continue to slope for a depth of one tread beyond the bottom riser.

Exception: Within dwelling units the handrail shall be permitted to extend, at the required height, to points directly above the top and bottom risers.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the exit corridors as required by 18.2.5.10. This was evidenced by the following:

1. The facility failed to maintain the corridors without dead ends greater than 30 feet in length. The corridor near the dining room extending to the two-hour fire wall exceeded 30 feet in length when the doors equipped with electro-magnetic devices were locked. The corridor was measured at 35 feet.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the exit directional signs as required. This was evidenced by the following:

1. The facility failed to install an exit signs above the cross corridor doors into the dining room corridor near the Chapel; and at the junction of the main corridor and the educational corridor.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the fire alarm system as required. This was evidenced by the following:

1. The facility failed to have the smoke detectors on the third floor installed in accordance with NFPA 72. The smoke detector for the elevator was mounted on the bottom edge of the structural beam and not in the beam pocket.

2-3.4.6.1 Flat Ceilings.
For ceiling heights of 12 ft (3.66 m) or lower, and beam or solid joist depths of 1 ft (0.3 m) or less, smooth ceiling spaces running in the direction parallel to the run of the beams or solid joists shall be used and one-half the smooth ceiling spacing shall be in the direction perpendicular to the run of the beams or solid joists. For beams over 1 ft (0.3 m) in depth, spot-type detectors shall be permitted to be located either on the ceiling or on the bottom of the beams.

For beam depths exceeding 1 ft (0.3 m) or for ceiling heights exceeding 12 ft (3.66 m), spot-type detectors shall be located on the ceiling in every beam pocket.

2. The smoke detectors located on the second floor in the Peak Care Unit failed have the proper coverage spacing. The corridors were equipped with drop down panels greater than 12 inches at ceiling level which created pockets and areas unprotected.

3. There were ceiling pockets without smoke detectors located in the second floor West wing corridor near the nourishment room and the first floor corridor near the chapel.

4. The second floor West wing nourishment room was open to the corridor and failed to be equipped with a smoke detector.

18.3.6.1 Corridors shall be separated from all other areas by partitions complying with 18.3.6.2 through 18.3.6.5. (See also 18.2.5.9.)

Exception No. 1: Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met:
(a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.
(d) The space does not obstruct access to required exits.

5. The facility failed to install smoke detectors in OR1 and the C-Section OR.

6. The front cross corridor doors to the second floor Peak Care Unit failed to release from the electro-magnetic hold open devices when the fire alarm system was tested.

7. The heat detector in the elevator equipment room on the first floor failed to be located within two feet of the fire sprinkler head to shut down power to the elevator prior to sprinkler activation.
3-9.4.2 If heat detectors are used to shut down elevator power prior to sprinkler operation, they shall be placed within 2 ft (610 mm) of each sprinkler head and be installed in accordance with the requirements of Chapter 2.

It was determined by observation or record review during the course of the survey on January 4-7, 2011 that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems and NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

1. The fire sprinkler heads located in the kitchen were loaded with foreign matter and need to be replaced.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the smoking regulations as required. This was evidenced by the following:

1. The facility failed to provide ashtrays of non-combustible materials and of safe design at the entrance to the building. The campus is non-smoking; however, there were cigarette butts observed in the downspout near the front entrance doors.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the cooking facility in accordance with 9.2.3, 19.3.2.6, NFPA 96. This was evidenced by the following:

1. The kitchen appliances were not located under the hood and aligned with the nozzles of the fixed fire suppression system. (staff relocated the appliances during the survey)

NFPA Standard 96 Section 9-1.2.2 requires that cooking appliances requiring protection not be moved, modified, or rearranged without prior reevaluation of the fire-extinguishing system by the system installer or servicing agent, unless otherwise allowed by the design of the fire-extinguishing system. Exception: Cooking appliances moved to perform maintenance and cleaning provided the appliances are returned to their original positioning prior to cooking operations.

NFPA 96 Section 9-1.2.3: All deep fat fryers shall be installed with at least a 16-inch space between the fryer and surface flames from adjacent cooking equipment. Exception: Where a steel or tempered glass baffle plate is installed at a minimum 8 inches in height between the fryer and surface flames of the adjacent appliance.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to maintain the egress corridors as required. This was evidenced by the following:

1. The facility failed to maintain the egress corridor at the dining room. There were vending machines located in the corridor obstructing the clear width of the exit pathway.

2. The facility failed to maintain the egress from the first floor ED staff lounge. The walk was covered with snow and ice.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011, the facility failed to maintain the medical gas storage area in accordance with NFPA 99. This was evidenced by the following:

1. The electrical outlets and switches were not maintained at a level of 5-feet above the floor surface in the medical gas storage area on the third floor.

NFPA-99, section 4-5.1.1.2 requires; "Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 5 ft (152 cm) above the floor as a precaution against their physical damage."

It was determined by observation, record review and staff interview during the course of the survey conducted on January 4-7, 2011, that the facility failed to install and maintain the environmental systems in the anesthetizing locations in accordance with NFPA 99. This was evidenced by the following:

1. A review of the facility's records failed to document the mechanical ventilation system supplying the anesthetizing locations had maintained a humidity level of 35% or greater in the existing OR1, newly opened OR3, or in the C-section OR.

During the walk-through inspection on January 5, 2011; the C-section OR humidity was observed at 21.9 % with a temperature of 60 degrees. At 09:30 on January 6, 2011, the humidity level was at 23.8%. Paperwork indicated humidity in the C-section OR was trending at approximately 20-25%.

Paperwork indicated humidity in OR1 was between 2 % and 9% between 16:00 January 3, 2011 and 15:00 January 4, 2011. Paperwork further indicated the humidity levels at approximately 5% during September, October, November, December 2010; and January and February 1011.

Paperwork indicated humidity in OR3 was 15% at 21:00 on January 4, 2011; 12% at 08:00 January 6, 2011.

NFPA 99 Section 5-4.1.1 requires that the mechanical ventilation system supplying anesthetizing locations have the capability of controlling relative humidity at a level of 35% or greater.

2. The ventilating system serving anesthetizing locations was not installed in accordance with NFPA 99 Section 5-4.1.2 and 5-4.1.3, as required. There was no smoke evacuation system installed in the existing OR1 and in the C-Section OR.

NFPA 99 Section 5-4.1.2: Supply and exhaust systems for anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. Section 5-4.1.3: Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

It was determined by observation and staff interview during the course of the survey conducted on January 4-7, 2011 that the facility failed to maintain the electrical system in accordance with National Electrical Codes. This was evidenced by the following:

1. The facility failed to maintain a minimum of 3 feet of clearance around the electrical panels located on the third floor.

2. The electrical wiring failed to be terminated in the junction box and the approved coverplate was missing from the electrical wiring junction box located above the ceiling tiles at the cross corridor doors to the Peak Care Unit (surgery unit).

3. The wiring junction box on the fire sprinkler riser in the first floor riser room failed to have an approved cover.

4. There was an extension cord attached to the wall and being used for permanent wiring in the first floor riser room to supply power to water meter box.