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Based on observation during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to maintain the interior finish in accordance with section 19.3.3.1 of the Life Safety Code. This was evidenced by the following:

During the walk through with the facility staff:

In the corridor from the Emergency Department entrance, a cork board of unknown classification measuring approximately 3' by 3' was fastened to the corridor wall. At the time of the survey no documentation was available demonstrating that the interior finish met the requirement of Class C interior finish or better as trim or incidental finish in accordance with 10.2.5.

The interior finish deficiency items were discussed during the survey and again during the exit conference.

Based on observation during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to maintain the interior finish in accordance with section 19.3.3.1 of the Life Safety Code. This was evidenced by the following:

During the walk through with the facility staff:

In room 100, used as a staff break room, there were two panels, approximately 4' x 8' each, of foam board approximately 1" thick fastened to the room wall. Cellular or foamed plastic shall not be used as interior wall finish in accordance with 10.2.4.3.

The interior finish deficiency items were discussed during the survey and again during the exit conference.

Based on observation, staff interview, and record review during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to maintain separation from corridors to use areas in accordance with sections 19.3.6.1, 19.3.6.2.1, and 19.3.6.5 of the Life Safety Code. This was evidenced by the following:

During the walk through with the facility staff:

1. The Physical Therapy Rehab Gym area located at the end of the ancillary wing was open to both corridors. None of the exceptions can be met as the area is a space used for patient treatment.
2. The Emergency Department registration area contains a pass through consisting of a round hole in the glass and a slot pass through below the glass and above the counter top which exceeds 80 square inches in area.
3. The main entry lobby and it ' s " mezzanine " level is open to the corridor. Exception number one items (b) and (c) to 19.3.6.1 are not met as the space does not contain smoke detection, quick response sprinklers and/or is not arranged to allow direct supervision of the space. Exceptions two through seven do not meet by definition.
4. The front business office and registration area is a suite which is not separated from the main entry lobby and subsequently the corridors.
5. Throughout the facility the corridor walls were observed to terminate above the grid ceiling and not continue to the underside of the of the floor or roof deck above. Exception number one to 19.3.6.2.1 is not met based on the inspection report from the facility fire sprinkler contractor dated December 5, 2011 indicating that numerous areas required additional sprinkler heads to be added to provide full coverage in accordance with NFPA 13. The lack of sprinkler coverage in areas throughout the hospital was confirmed through observation during the walkthrough.

6. Lay in tile and grid ceilings in various locations throughout contained gaps, holes, and corners missing preventing the ceiling from being constructed to limit the transfer of smoke.

Modification of the fire sprinkler system to provide complete coverage to obviate item number three of this deficiency was discussed during the survey. Item number one was discussed during the exit conference.

Based on observation during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to maintain the doors to the corridor in accordance with section 19.3.6.3 of the Life Safety Code. This was evidenced by the following:
During the walk through with the facility staff:

1. The following doors did not latch into their frame:
a. Rooms 103, 117, 112 (corrected during the survey)
b. Emergency Department holding room
c. Left leaf of the pair of doors into the kitchen.
d. Rooms 108, 109, 110, 111 ICU sliding doors are not equipped with latching hardware.

2. The following doors were obstructed from properly closing and latching:
a. Room 103 - Door was obstructed by the bed which was moved into the path of door swing. (corrected during the survey)

3. The rooms located within the ancillary wing contained roller latches and an additional latch with a thumb-turn on the inside requiring the use of a key from the corridor side to unlock. Many of the latches were capable of having the latch dogged in via the thumb-turn preventing the doors from latching. Roller latches are not permitted as a means of keeping the door closed per CMS S&C-03-21

The corridor door latching deficiency items were discussed during the survey and again during the exit conference.

Based on observation during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to maintain and protect vertical openings in accordance with section 19.3.1.1 of the Life Safety Code. This was evidenced by the following:

The main entry lobby contains an upper level " mezzanine " containing offices and meeting rooms. Unprotected openings in accordance with 8.2.5.5 are not permitted.

The area does not meet the requirements of 8.2.5.8 for unenclosed vertical openings due to the following:

1. The lobby and upper floor opening is not separated from corridors as the lobby is open to the corridors leading to multiple other areas of the facility.

2. The opening is a required means of egress from payroll and the other upstairs office space.

The area does not meet the requirements of 8.2.5.6 for atriums due to the following:

3. The entire building is not protected throughout by an approved automatic sprinkler system

4. An engineering analysis has not been performed in accordance with 8.2.5.6 (5)

5. An engineered smoke control system is not installed in accordance with 8.2.5.6 (6)

The vertical opening deficiency items were discussed during the survey and again during the exit conference.

Based on observation during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to maintain the smoke barrier doors in accordance with section 19.2.2.2.6 of the Life Safety Code. This was evidenced by the following:

During the walk through with the facility staff:

1. The doors to the Emergency Department suite which are within a smoke barrier wall were held open by closer hold opens that are not equipped with a means to release upon activation of the manual fire alarm system, activation of smoke detection systems, or the automatic sprinkler system.

2. Door accessing the stair enclosure at the top of the " mezzanine " level was held open by a closer hold open that is not equipped with a means to release upon activation of the manual fire alarm system, activation of smoke detection systems, or the automatic sprinkler system.

The door closing deficiency items were discussed during the survey and again during the exit conference.

Based on observation, staff interview, and record review during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to maintain the fire rated smoke barrier walls in accordance with section 19.3.7.3 of the Life Safety Code. This was evidenced by the following:

1. Smoke barriers walls were constructed of metal studs with lath and plaster on one side only. At the time of the survey no documentation was available demonstrating that the wall was constructed with a fire resistance rating of not less than ? hour.

2. There were various penetrations throughout that were not completely or adequately sealed to restrict the movement of smoke.

Staff acknowledged the single sided lath and plaster construction of the smoke barrier and penetrations during the survey.

Based on observation and staff interview during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to maintain the smoke barrier doors in accordance with section 19.3.7.6 of the Life Safety Code.
This was evidenced by the following:

During the walk through with the facility staff:

Smoke barrier doors at numerous locations failed to close properly when released. Door coordinators were preventing one leaf from completely closing. Doors which did not completely close were located at the following locations:

1. Smoke barrier doors to ancillary wing, south hall.

2. Smoke barrier doors at south side of north/south central hall, south of emergency department, north of ancillary wing.

3. Smoke barrier doors to the patient wing, north hall.

The smoke barrier door closing deficiency items were discussed during the survey and again during the exit conference.

Based on observation and record review during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to protect hazardous areas in accordance with section 19.3.2.1 of the Life Safety Code. This was evidenced by the following:

During the walk through with the facility staff:

1. Respiratory supplies were stored in a former bathroom labeled " site bath " . The door is double swing with no stop on the frame and is not smoke resistive. This condition was replicated in other bathrooms used for storage.

2. The closet in the x-ray room contains hazardous storage, the room was not sprinkler protected and the door was not on a self or automatic closer.

3. The elevator vestibule to the " soiled " elevator was used as a trash holding area, one leaf of the pair of doors contained a manual flush-bolt which was not latched preventing isolation of the hazardous area. The door to the elevator car was left in the open position leaving the hazardous area open to the elevator.

4. The dining room is not separated from the kitchen due to an open pass through and a door, with the grill located within the dining room space, the dining room and kitchen are considered to be one common hazardous area. The following items were found to be deficient in protecting this hazardous area:
a. The sprinkler coverage within the dining area is incomplete; heads exceeded maximum spacing from the walls.
b. An ordinary temperature sprinkler head within the kitchen was located within 1ft of a supply diffuser.
c. No sprinkler coverage in the walk in coolers.

The deficient sprinkler protection results in the requirement that the area be enclosed by one-hour fire resistance rated construction. The following items are deficient and may be obviated by correcting the sprinkler deficiencies:
d. The door to the corridor from the dining area is not rated.
e. The door and frame leading to human resources office is not rated.
f. There was no documentation provided at the time of survey to indicate the walls are of one-hour rated construction.

5. The mezzanine payroll storage closet was not sprinkler protected and the access door to the space above was left in an open position.

The hazardous area deficiency items were discussed during the survey and again during the exit conference.

Based on observation during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to maintain travel distance to exits in accordance with section 19.2.5.8 of the Life Safety Code. This was evidenced by the following:

During the walk through with the facility staff:

1. The surgical and operating room area is classified as a suite containing two intervening rooms. Travel distance within the suite exceeded 50ft as it was measured to be 65 ft of travel from operating room two. A pair of doors that was within 50 ft of travel was locked and marked as not an exit.
2. The front business office is a suite which contained three intervening rooms and therefore exceeds the allowable travel distances within suites.
The travel distance deficiency items were discussed during the survey and again during the exit conference.

Based on observation and staff interview during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to provide and maintain a means of egress so arranged that exits are readily accessible at all times in accordance with section 19.2.1 of the Life Safety Code. This was evidenced by the following:

During the walk through with the facility staff:

1. A gurney was located within the stair enclosure near the emergency department entrance, a required means of egress from the basement. An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit.

2. A combustible plywood sign directing traffic to the emergency department was located within the stair enclosure near the emergency department entrance, a required means of egress from the basement. An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit.

3. The stair enclosure from the " mezzanine " level contained wooden mail boxes with mail, a waste basket and a large wooden box. An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit.

4. The exit doors from the vestibule adjacent to the operating suite on the north side were equipped with an incomplete access control system. The optical sensor was mounted in an offset location and did not reliably release the locking mechanism. There was no manual release device in accordance with 7.2.1.6.2 (c).

5. The ICU patient rooms located at the end of the patient wing were equipped with a lock that would require the use of a key from the inside to egress from the room where it to be locked. Doors located n a required means of egress shall not be equipped with a latch or lock that requires the use of a key from the egress side.

6. Doors from rooms in the ancillary wing are equipped with a latch located between 51 " and 58 " in height which contain a thumb-turn on the egress side and a key lock on the outside of the door. Releasing devices shall be located not less than 34 " and not more than 48 " above finished floor.

7. Three wheelchairs were stored in the corridor near the emergency department entrance, they were observed to be there the morning of September 19th at approximately 9:00am and remained there on September 20th at approximately 11:00am.

8. Numerous tables containing books were located on both sides of the corridor open to the entry lobby for a book sale. These tables restricted the corridor width and prevented the exits from being readily accessible.

9. The vending machine located in the entry corridor reduced the width of the corridor and may prevent the exits from being readily accessible.

The means of egress deficiency items were discussed during the survey and again at the exit conference.

Based on observation, staff interview, and record review during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to maintain the battery backed-up emergency lighting in accordance with section 7.9 of the Life Safety Code. This was evidenced by the following:

During record review:

1. The logs provided indicated that the battery backup emergency lighting throughout was tested for 90 seconds monthly and 30 minutes annually. Testing was not conducted for adequate duration annually. Lighting shall be tested annually for 90 minutes in accordance with 7.9.3.

During the walk through with the facility staff:

2. Emergency and exit light in the building lobby failed to function when tested.

The emergency lighting deficiency items were discussed during the survey and again at the exit conference.

Based on observation, staff interview, and record review during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to maintain the battery backed-up emergency lighting in accordance with section 7.9 of the Life Safety Code. This was evidenced by the following:

During record review:

1. The logs provided indicated that the battery backup emergency lighting throughout was tested for 90 seconds monthly and 30 minutes annually. Testing was not conducted for adequate duration annually. Lighting shall be tested annually for 90 minutes in accordance with 7.9.3.

During the walk through with the facility staff:

2. Emergency light in the building lobby failed to function when tested.

The emergency lighting deficiency items were discussed during the survey and again at the exit conference.

Based on observation, staff interview, and record review during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to maintain the battery backed-up emergency lighting in accordance with section 7.9 of the Life Safety Code. This was evidenced by the following:

During record review:

1. The logs provided indicated that the battery backup emergency lighting throughout was tested for 90 seconds monthly and 30 minutes annually. Testing was not conducted for adequate duration annually. Lighting shall be tested annually for 90 minutes in accordance with 7.9.3.

During the walk through with the facility staff:

2. Emergency light in the penthouse failed to function when tested.

3. Emergency light in the MRI trailer failed to function when tested.

4. Exit light in MRI trailer failed to function when tested.

5. Emergency lighting in the following locations was plugged into a wall outlet via a cord which is not suitable for maintaining the batteries to insure illumination is provided automatically in accordance with 7.9.2.4:
a. Lab emergency lights plugged into wall outlets utilizing an added extension cord.
b. Penthouse emergency light plugged into a wall outlet utilizing a cord.

The emergency lighting deficiency items were discussed during the survey and again at the exit conference.

Based on observation, staff interview, and record review during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to conduct fire drills in accordance with sections 19.7.1.2 and 4.7 of the Life Safety Code. This was evidenced by the following:

During record review:

1. Fire drills were not conducted quarterly on each shift to familiarize personnel with the signals and emergency action required under varied conditions in accordance with 19.7.1.2
a. Records indicated that many items logged in the Fire drill log for 2011 and 2012 as " unannounced fire alarms " were false alarms or activations of the alarm system. These activations of the fire alarm system shall not be counted towards the quarterly drills. Drills shall be planned, conducted, supervised and evaluated by competent personnel to simulate emergency conditions.
b. Records indicated that many items logged in the Fire drill log for 2011 and 2012 activations of the fire alarm system for testing purposes and staff was advised not to respond to the alarm activation. Five of the nine recorded drills for 2012 were for one of the following: Backflow testing, Ansul system test, 5 year sprinkler obstruction testing.
c. The Facilities Services Director / Safety Officer indicated there were two twelve hour shifts daily. The fire drill log reflected two shifts, first and second. For the purposes of fire drills there should be additional shifts accounted for as staff does not work twelve hour days, seven days a week.

During the walk through with the facility staff:

2. A fire drill was conducted on September 20, 2012 at approximately 9:30am. Staff responding to the simulated emergency condition demonstrated the lack of practice of the emergency plan. The Staff did not respond in accordance with the facilities emergency plan and procedures in place without outside prompting.

The emergency lighting deficiency items were discussed during the survey and again at the exit conference.

Based on observation during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to install the Fire Alarm System in accordance with section 19.3.4 of the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

During the walk through with the facility staff:

1. The strobe spacing in the central corridor between the patient and ancillary wing measured in excess of 15 feet per corridor spacing requirements of NFPA 72, section 4-4.4.2.2, measured from the south end of the corridor as defined by the smoke barrier doors.

2. The MRI trailer fire alarm system was not connected to the building fire alarm system and as such does not provide emergency forces notification in accordance with 19.3.4.3.2. The lack of interconnectivity does not provide automatic notification to other facility staff who may be responsible for responding in emergency conditions.

The fire alarm deficiency items were discussed during the survey and again at the exit conference.

Based on observation during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to install the automatic fire sprinkler system in accordance with NFPA 13 This was evidenced by the following:
During the walk through with the facility staff:

1. The ceiling in the following locations contained open plastic gridded panels which is not considered as a ceiling for sprinkler installation purposes. The sprinkler heads in those rooms exceed the spacing from the ceiling above in accordance with NFPA 13, section 5-6.4.1:
a. The basement health information office.
b. Vestibule for the exit adjacent to the surgical suite.

2. The pendant sprinkler heads in the following locations exceed the spacing from the ceiling in obstructed construction in accordance with NFPA 13, section 5-6.4.1.2:
a. In the basement outside the elevator equipment room.
b. In the receiving garage area.
c. In the penthouse where extended adjacent to a duct to provide coverage under the duct.

3. The sprinkler heads in the following locations were obstructed from the spray pattern fully developing resulting in incomplete coverage:
a. The sprinkler head outside room 110 was obstructed by the light fixture immediately adjacent which extended below the deflector.
b. The sprinkler head in the hallway outside the kitchen restroom obstructed by the light fixture immediately adjacent which extended below the deflector.
c. At the kitchen lockers sprinkler coverage was obstructed by the wall from reaching the locker area.
d. The sprinklers in the med-gas storage room were obstructed by a duct located below from providing complete coverage to the room.

4. A sprinkler head in the kitchen was of ordinary temperature and was located within 1 ' of a ceiling supply diffuser.

5. A portion of the corridors around the emergency department waiting area had been changed to quick response sprinkler heads, the adjacent corridor space within the same compartment were of the standard response type. The lintels present measured less than 8 " and do not provide compartment separation. When sprinklers are converted to quick response all sprinklers in the compartmented space shall be changed in accordance with NFPA 13, section 5-3.1.5.2.

The fire sprinkler installation deficiency items were discussed during the survey and again at the exit conference. Areas with no sprinkler coverage or incomplete coverage were not considered deficient but credit for the building being fully sprinkler protected could not be given were required for other items.

Based on observation during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13 and 25. This was evidenced by the following:
During the walk through with the facility staff:

1. There was foreign material loading consisting primarily of lint and in some locations synthetic fibers on numerous sprinkler heads throughout the facility. Sprinklers shall be free of foreign material in accordance with NFPA 25, section 2-2.1.1. Location affected include but are not limited to: Room 312, radiology directors office, switchboard room, sterile processing, IT office, PT storage.

2. There was paint present on the sprinkler head in room 312. Sprinklers shall be free of paint in accordance with NFPA 25, section 2-2.1.1.

3. The sprinkler escutcheon in the bathroom in room 340 was deformed. Sprinklers shall be free of physical damage in accordance with NFPA 25, section 2-2.1.1.

The fire sprinkler maintenance deficiency items were discussed during the survey and again at the exit conference.

Based on observation, staff interview, and record review during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to provide and maintain portable fire extinguishers in accordance with section 19.3.5.6 of the Life Safety Code and NFPA 10. This was evidenced by the following:

During the walk through with the facility staff:

1. The two portable extinguishers located within the penthouse were last marked as visually inspected in June 2012. Portable extinguishers shall be visually inspected monthly in accordance with NFPA 10, section 4-3.1.

2. A type K extinguisher should be provided at the grill located within the dining area in accordance with NFPA 10, section 3-7.

The portable fire extinguisher deficiency items were discussed during the survey and again at the exit conference.

Based on observation, staff interview, and record review during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to provide and maintain portable fire extinguishers in accordance with section 38.3.5 of the Life Safety Code and NFPA 10. This was evidenced by the following:

During the walk through with the facility staff:

1. No portable extinguisher was present in suite #2

2. The portable extinguisher in suite #1 was mounted too high with the handle at approximately 6 ' above the floor. Extinguishers under 40lbs shall be installed so that the top of the extinguisher is no more than 5 ' above the floor.

3. The portable extinguisher in the Cardiac rehabilitation suite was mounted too high with the handle at approximately 5 ' 5 " above the floor. Extinguishers under 40lbs shall be installed so that the top of the extinguisher is no more than 5 ' above the floor

The portable fire extinguisher deficiency items were discussed during the survey and again at the exit conference.

Based on staff interview and record review during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to provide a smoking policy to evaluate and classify patients as not responsible in accordance with section 19.7.4 of the Life Safety Code. This was evidenced by the following:

During record review:

The smoking policies provided at the time of the survey did not contain any provisions to classify patients who smoke as responsible or not responsible. Smoking by patients classified as not responsible shall be prohibited except when under direct supervision.
The smoking policy deficiency item was discussed during the survey and again at the exit conference.

Based on observation, staff interview, and record review during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to maintain draperies, curtains and other loosely hanging fabrics in accordance with sections 19.7.5.1 and 10.3.1 of the Life Safety Code. This was evidenced by the following:
During the walk through with the facility staff:

1. The draperies in the Respiratory Therapy Call Room were not marked with tags as inherently flame resistant. There was no documentation available at the time of survey indicating the draperies had been treated to be flame resistant. (The draperies were removed during the survey)

2. The curtains located near the end of the patient corridor were not marked with tags as inherently flame resistant. There was no documentation available at the time of survey indicating the curtains had been treated to be flame resistant.

3. The curtains located in X-ray changing area were not marked with tags as inherently flame resistant. There was no documentation available at the time of survey indicating the curtains had been treated to be flame resistant.

4. Silk plants as decorations were present in the Surgical waiting area. There was no documentation available at the time of survey indicating the decorations had been treated to be flame resistant. (The silk plants were removed during the survey)

The loose hanging fabrics and decorations deficiency item was discussed during the survey and again at the exit conference.

Based on observation, staff interview, and record review during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to maintain the Medical Gas and Vacuum Systems in accordance with section 19.3.2.4 of the Life Safety Code. This was evidenced by the following:
During record review:

1. The documentation provided by the facility, from an independent contractor dated July 11, 2012, indicated the following deficiencies:
a. The bulk tank was not grounded. If electric heaters are used to provide the primary source of heat to the vaporizing system, the vaporizing system shall be electrically grounded in accordance with NFPA 50, section 3-4.4
b. There was not a liquid level low alarm present. Medical Gas Alarms shall be provided in accordance with NFPA 99, section 4-3.1.2.2.
c. There was not a reserve low pressure alarm present. Medical Gas Alarms shall be provided in accordance with NFPA 99, section 4-3.1.2.2.
The facility was not able to provide documentation to show the correction of the above items indicated in the last inspection report.

During the walk through with the facility staff:

2. At the bulk oxygen location there were multiple trees in close proximity. A clearance of 50 feet from solid materials that burn rapidly shall be maintained in accordance with NFPA 50, section 2-2.7 or separated in accordance with 2-2.14

3. The reserve oxygen supply in twenty-eight H-tanks located adjacent to the bulk tank were all (28 of 28 tanks) labeled with an expiration date prior to the date of the survey. Oxygen cylinders shall be tested and maintained in accordance with NFPA 99, section 4-3.1.1.1.

4. Within the operating suite the Medical Gas zone valve boxes at the following locations were obstructed by carts and equipment placed in front of the panel:
a. Pre-op and soiled - obstructed by cart.
b. Sterile corridor - obstructed by crash cart.
Zone valves shall be located an maintained to be visible and readily accessible at all times for use in an emergency in accordance with NFPA 99, section 4-3.1.2.3.

The medical gas deficiency items were discussed during the survey and again at the exit conference.

Based on observation and staff interview during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to protect anesthetizing locations in accordance with section 19.3.2.3 of the Life Safety Code and NFPA 99. This was evidenced by the following:

During the walk through with the facility staff:

1. According to the Facilities Services Director, the operating rooms did not contain a mechanical ventilation system arranged to automatically vent smoke and products of combustion and prevent recirculation in accordance with NFPA 99, sections 5-4.1.2 and 5-4.1.3.

2. The humidity levels within the operating rooms were not controlled to a level of 35% or greater at the time of the survey.
a. Operating room one, the wall mounted gauge was inoperable. The battery powered desk humidity gauge read 23% at the time of survey.
b. Operating room two, The humidity gauge read 22% at the time of survey.

The anesthetizing location deficiency items were discussed during the survey and again during the exit conference.

Based on observation, staff interview, and record review during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to maintain penetrations in smoke barriers by ducts in accordance with section 8.3.6 of the Life Safety Code. This was evidenced by the following:
During record review:

The documentation provided by the facility, from an independent contractor dated August 20, 2008 indicated dampers which were not testable. The report indicated that the fire smoke damper separating the laboratory from the corridor contained cables running through the damper obstructing the operation. As a result this opening within a smoke barrier is not protected in accordance with 8.3.6. In addition this damper was not tested within the interval specified by CMS S&C-10-04-LSC.

The damper testing deficiency items were discussed during the survey and again during the exit conference.

Based on observation, staff interview, and record review during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to install the Type I emergency backup generator in accordance with NFPA 99, section 3.4.2.2.2. This was evidenced by the following:

During the walk through with the facility staff:

1. The generator installed is a 350KW Generator which supplied two transfer switches which were not labeled in a manner indicating proper arrangement. Transfer switches were labeled as: #1, Lab, and #2, surgical and autoclave. There was no documentation available at the time of survey indicating that the electrical distribution was arranged into a Critical Branch, Life Safety Branch, and Emergency System. The only electrical plan provided indicated a previous configuration with a single transfer switch prior to installation of the current generator.

2. The transfer switch locations were not equipped with battery backup lighting in accordance with NFPA 110, Section 5-3.1.

The generator deficiency items were discussed during the survey and again during the exit conference.

Based on observation, staff interview, and record review during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to install and maintain electrical wiring in accordance with NFPA 70, National Electrical Code. This was evidenced by the following:

During the walk through with the facility staff:

1. There was an electrical outlet behind the bed in sleep lab room 1 which was not securely fastened.

2. The following rooms or suites contained extension cords or temporary cords used as a substitute for permanent wiring:
a. The Cardio Services manager ' s office contained an extension cord installed into wire mould.
b. Nuclear Medicine 341 contained extension cords powering a window A/C unit and an additional portable cooling unit.
c. The Nuclear Medicine Hot Lab contained an extension cord supplying power to a power strip.
d. The CT room had a retractable extension cord reel installed to the wall.
e. Emergency lighting located in the Lab and penthouse utilized an extension cord to supply power.
f. The Lab contained an extension cord running the length of the counter.
g. The Sterile Processing room contained an air compressor with a very long field fabricated power cord which was then plugged into a power strip.

3. The following rooms or suites contained multi-outlet power strips or plugs " daisy-chained " in series and/or used not in accordance with their listing:
a. Basement telephone room contained multi-outlet devices in series. A multi-tap was installed into the outlet which fed a power strip which then powered multi-outlet UPS devices which may result in potential circuit overloading.
b. Numerous office locations including but not limited to: three offices within the front business office, contained UPS devices used in series with power strips which may result in potential circuit overloading.

The electrical deficiency items were discussed during the survey and again during the exit conference.

Based on observation during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly in accordance with CMS Guidelines and the CFR. This was evidenced by the following:

During the walk through with the facility staff:

ABHR ' s located within the ancillary wing were located above carpeting in multiple locations. AHBR ' s may only be located above carpeting if the building is fully sprinkler protected. The building is currently classified as partially sprinkler protected.

The Alcohol Based Hand Rub (ABHR) dispenser deficiency item was discussed during the survey and again during the exit conference.