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140 NUTT ROAD

PHOENIXVILLE, PA 19460

No Description Available

Tag No.: K0011

Based on observation and interview, the facility failed to maintain communicating door openings and the proper fire resistance rating of two hour fire-resistant common walls on three of four floors.

Findings include:

1. Observation on March 29, 2010, at 2:05 PM revealed penetrations in the common wall above the doors at the 4 South elevators.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 2:05 PM, confirmed the penetrations in the common wall.

2. Observation on March 29, 2010, at 3:00 PM revealed the fire doors in the 3rd
Floor separation wall at the Medical Office Building (MOB) Bridge did not close/latch into the frame.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 3:00 PM, confirmed the doors did not close/latch.

3. Observation on March 30, 2010, at 9:30 AM revealed three (3) conduit penetrations in the separation wall above the fire doors outside the 2nd Floor elevators.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:30 AM, confirmed the conduit penetrations.

4. Observation on March 30, 2010, at 9:55 AM revealed an unsealed penetration, at the 4th Floor double corridor doors, outside the IT Room, around red wires on left wall.

Interview with the Director of Plant Operations on March 30, 2010, at 9:55 AM confirmed that the above condition exists.

No Description Available

Tag No.: K0012

Based on observation and interview, the facility failed to maintain proper building construction type in numerous areas in two (2) of six (6) floors.

Findings include:

1. Observation on March 29, 2010, between 1:51 PM and 2:13 PM revealed missing fire spray on structural beams during the following times and at the following locations:

a) 1:51 PM, missing fire spray on a structural beam in two locations at the Ground/1st Floor firewall next to the Sprinkler Room and above a wall mural.
b) 2:53 PM, missing fire spray on a structural beam in the Ground/1st Floor Morgue restroom.
c) 2:13 PM, missing fire spray on a structural beam above door to copier room in Ground/1st Floor Central Storage Room.

Interview with the Plant Operations Manager on March 29, 2010, at the above times confirmed the missing fire spray on structural beams.

2. Observation on March 30, 2010, at 9:50 AM revealed that there was an unprotected structural steel beam, above the New Addition Ground Floor cross-corridor doors, by the Mail Room.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 9:50 AM, confirmed the unprotected steel beam.

3. Observation on March 30, 2010, at 11:00 AM in the 2nd Floor Medical Records Room revealed missing fire spray on a structural beam, above the "charts to be filed" section of shelving.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:00 AM confirmed the missing fire spray.

4. Observation on March 30, 2010, at 11:06 AM in the 2nd Floor new Medical Records Room revealed missing fire spray on a structural beam, above the clock.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:06 AM confirmed the missing fire spray.

No Description Available

Tag No.: K0017

Based on observation and interview, the facility failed to maintain the required construction of corridor walls on two floors.

Findings include:

1. Observation on March 30, 2010, at 9:22 AM revealed there was an unsealed corridor wall penetration above the suspended ceiling on the 4th Floor, at Patient Room 414.

Interview with the Director of Plant Operations on March 30, 2010, at 9:22 AM confirmed the corridor wall penetrations.

2. Observation on March 30, 2010, at 10:20 AM revealed there was an unsealed corridor wall penetration above the suspended ceiling, inside a 2" conduit on the 3rd Floor, in the Elevator Lobby, over the Exit Stairs Door.

Interview with the Director of Plant Operations on March 30, 2010, at 10:20 AM confirmed the corridor wall penetrations.

3. Observation on March 30, 2010, at 11:20 AM revealed there was an unsealed corridor wall penetration above the suspended ceiling, inside a conduit on the 3rd Floor, in the corridor at the Linen Chute Room and Surgical Waiting Area.

Interview with the Director of Plant Operations on March 30, 2010, at 11:20 AM confirmed the corridor wall penetrations.

No Description Available

Tag No.: K0018

Based on observation and interview, it was determined the facility failed to maintain doors protecting corridor openings to be smoke resistant.

Findings include:

1. Observation on March 30, 2010, at 8:55 AM revealed a gap greater than 1/8 inch between the meeting edges of the double doors entering the 3rd Floor Endoscopy suite.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 8:55 AM confirmed the gap between the doors.

2. Observation on March 30, 2010, at 9:00 AM revealed gap greater than 1/8 inch between the meeting edges of the double doors entering the 3rd Floor Intensive Care Unit.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:00 AM confirmed the gap between the doors.

No Description Available

Tag No.: K0020

Based on observation and interview, the facility failed to protect openings through the floor assembly in one location, on one of four floors.

Findings include:

1. Observation on March 29, 2010, at 2:55 PM revealed that there was an unsealed penetration of both the floor slab and ceiling slab behind Chiller #2 in the 5th Floor Mechanical Room.

Interview with the Director of Plant Operations on March 29, 2010, at 2:55 PM confirmed the unsealed floor/ceiling penetration.

No Description Available

Tag No.: K0025

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of smoke barrier walls in one location, on one of four floors.

Findings include:

1. Observation on March 29, 2010, at 2:17 PM revealed the unsealed smoke barrier penetrations around the topside of a conduit and around the left side of duct work, between the flange and drywall, located above the cross-corridor doors by elevators 11 and 12.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:17 PM confirmed the unsealed penetrations.

No Description Available

Tag No.: K0027

Based on observation and interview, the facility failed to maintain door openings in smoke barriers on one floor.

Findings include:

1. Observation on March 29, 2010, at 2:20 PM revealed the double corridor smoke barrier doors, on the 5th Floor outside Patient Room 515, needed a coordinator adjustment to close properly.

Interview with the Director of Plant Operations on March 29, 2010, at 2:20 PM confirmed the above condition exists.

2. Observation on March 30, 2010, at 10:17 AM revealed the corridor smoke barrier door, on the 3rd Floor to the Surgical Waiting Area, was being held open by an unauthorized door hold-open device (wooden chock).

Interview with the Director of Plant Operations on March 30, 2010, at 10:17 AM confirmed the above condition exists.

3. Observation on March 30, 2010, at 10:20 AM revealed the corridor smoke barrier door, on the 3rd Floor, from the Surgical Waiting Area to behind the Information Desk, was being held open by an unauthorized door hold-open device (wooden chock).

Interview with the Director of Plant Operations on March 30, 2010, at 10:20 AM confirmed the above condition exists.

No Description Available

Tag No.: K0029

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of hazardous areas on three of four floors.

Findings include:

1. Observation on March 29, 2010, at 2:35 PM revealed an unsealed penetration of the one hour fire-rated 4th Floor Soiled Utility room in the wall above the sink, across from Room #465.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:35 PM confirmed the unsealed penetration.

2. Observation on March 29, 2010, at 2:40 PM revealed the 4th Floor Equipment Storage room door did not close/latch, across from Room #464.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 2:40 PM confirmed the door did not latch.

3. Observation on March 29, 2010, at 2:50 PM revealed an unsealed penetration of the one hour fire-rated Ground Floor Soiled Workroom, inside and around a metal sleeve containing a green MC cable, located in the shared Environmental Services Closet wall.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 2:50 PM confirmed the unsealed penetration.

4. Observation on March 30, 2010, at 9:45 AM revealed an unsealed penetration of the one hour fire-rated shared wall, with shell space, across from the 2nd Floor Ladies Room.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:45 AM confirmed the unsealed penetration.

5. Observation on March 30, 2010, at 9:50 AM revealed an open conduit in the 2nd Floor one hour fire-rated shared wall, with shell space, near the strobe light.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:50 AM confirmed the unsealed penetration.

6. Observation on March 30, 2010, at 10:15 AM revealed two (2) penetrations and one (1) wire penetration of the side walls of the 2nd Floor Soiled Utility Room across from Room #253.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 10:15 AM confirmed the unsealed penetrations.

No Description Available

Tag No.: K0030

Based on observation and interview, the facility failed to maintain the proper fire resistance rating of hazardous areas and failed to ensure that doors to hazardous areas were self-closing in one location, on one of four floors.

Findings include:

1. Observation on March 31, 2010, at 8:45 AM revealed that the door closure was removed to the Ground Floor Snack Bar corridor door, which is part of the Gift Shop hazardous area enclosure.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 8:45 AM confirmed that the closure was removed.

2. Observation on March 31, 2010, at 8:45 AM revealed a large unsealed penetration over the Ground Floor Snack Bar kitchen hood, below and above the ceiling tile, which is part of the Gift Shop hazardous area enclosure.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 8:45 AM confirmed the unsealed penetration.

No Description Available

Tag No.: K0033

Based on observation and interview, the facility failed to maintain the fire resistance rating of exit components to provide a continuous path of escape.

Findings include:

1. Observation on March 29, 2010, at 2:40 PM revealed the Ground Floor Main Building Security Office, by the New Addition, lacked a 1 ½ hour fire-rated door and door frame.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:40 PM, confirmed the above deficiency.

2. Observation on March 30, 2010, at 9:21 AM revealed an approximate one inch by twelve inch (1" x 12") opening, at the top of the shared stair tower wall, in the 3rd Floor Electrical Closet at the Nurses' Station on the ICU/MICU side.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:21 AM, confirmed the stair wall penetration.

3. Observation on March 30, 2010, at 11:30 AM revealed two (2) penetrations, and three (3) wire penetrations into the stair tower foyer, next to the 2nd Floor service elevator #2.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:30 AM confirmed the penetrations in the wall.

4. Observation on March 31, 2010, between 9:00 AM and 10:00 AM, revealed the following deficiencies for the North Stair Tower #1, next to Radiology, on the Ground Floor.

a) 9:00 AM, on the Mechanical Room side, a speaker was recessed into the concrete block wall degrading the 2-hour status.
b) 9:05 AM, on the Mechanical Room side, an unsealed penetration around a conduit.
c) 9:30 AM, between the Stair Tower and the Mechanical Room, a 1 1/2 -hour rated door had been removed, the opening was then in-filled with metal studs and a single layer of 5/8 " wallboard on each side, degrading the 2-hour status.

Interview with the Director of Plant Operations on March 30, 2010, at 10:00 AM confirmed the above deficiencies.

No Description Available

Tag No.: K0034

Based on observation and interview, the facility failed to ensure that stairways used as exits were not used for any purpose which has the potential to interfere with egress for one instance on the Ground Floor.

Findings include:

1. Observation on March 31, 2010, at 9:15 AM revealed that there was storage of a five foot long, four-inch diameter piece of conduit (Approx. size), in the North Stair Tower #1

Interview with the Director of Plant Operations on March 31, 2010, at 9:15 AM confirmed the above storage.

2. Observation on March 31, 2010, at 9:15 AM revealed that there was data wiring running through North Stair Tower #1

Interview with the Director of Plant Operations on March 31, 2010, at 9:15 AM confirmed the above condition.

No Description Available

Tag No.: K0038

Based on observation and interview, the facility failed to ensure that exit access was maintained readily accessible to a public way at one exit discharge within the entire facility.

Findings include:

Observation on March 30, 2010, at 2:45 PM, revealed that the 1st Floor exit egress outside of the Plant Operations Office was blocked by six (6) large laundry storage bins.

Interview with the Director of Plant Operations on March 30, 2010, at 2:45 PM confirmed the bins were blocking the exit egress.

No Description Available

Tag No.: K0039

Based on observation and interview, the facility failed to ensure that exit access corridors were maintained clear and unobstructed in two (2) locations on two (2) of six (6) floors.

Findings include:

1. Observation on March 30, 2010, between 9:00 AM and 10:00 AM, revealed the following obstruction on the 4th Floor, on both East to West corridors: in the North, two blood pressure machines, and in the South, two blood pressure machines and a wheel chair.

Interview with the Director of Plant Operations on March 30, 2010, at 10:00 AM confirmed the above storage in the corridor.

2. Observation on March 30, 2010, at 11:53 AM revealed six (6) large laundry storage bins in the 1st Floor corridor near the Plant Operations Office.

Interview with the Director of Plant Operations on March 30, 2010, at 11:53 AM confirmed the bins obstructed the corridor.

No Description Available

Tag No.: K0046

Based on observation and interview, the facility failed to ensure that emergency lighting was properly tested and maintained in one (1) location on one (1) of six (6) floors.

Findings include:

Observation on March 30, 2010, at 10:49 AM revealed an emergency back-up light in the 1st Floor shell space had an inoperative battery.

Interview with the Plant Operations Manager on March 30, 2010, at 10:49 AM confirmed the inoperative battery back-up light.

No Description Available

Tag No.: K0051

Based on observation and interview, the facility failed to ensure fire alarm components were installed or maintained properly in one (1) room on one (1) of six (6) floors.

Findings include:

Observation on March 30, 2010, at 3:33 PM revealed that there was one (1) smoke detector placed in a plastic bag in the 1st Floor Maintenance Room, near the door and next to the Plant Operations Office.

Interview with the Plant Operations Manager on March 30, 2010, at 3:33 PM confirmed the smoke detector was placed in a plastic bag.

No Description Available

Tag No.: K0054

Based on documentation review, observation and/or interview, the facility failed to maintain required fire alarm system or smoke detectors throughout the entire facility.

Findings include:

1. Documentation review on March 29, 2010, between 10:00 AM and 12:30 PM revealed 13 smoke detectors failed during the facility's last sensitivity inspection by Simplex on 3/8/10 and were not repaired/replaced.

Interview with the Plant Operations Manager on March 29, 2010, at 12:30 PM confirmed that the facility had no documentation reflecting that the smoke detectors had been repaired or replaced.

2. Observation on March 30, 2010, at 9:30 AM revealed that a new smoke detector had been installed within the airflow of a ceiling diffuser, on the 4th Floor in the East End Connector corridor.

Interview with the Director of Plant Operations on March 30, 2010, at 9:30 AM confirmed the above condition exists.

3. Observation on March 30, 2010, at 10:15 AM revealed the ceiling-mounted smoke detector was not properly mounted to its box on the 3rd Floor, at the Information Desk.

Interview with the Director of Plant Operations on March 30, 2010, at 10:15 AM confirmed the above condition exists.

No Description Available

Tag No.: K0062

Based on observation and interview, it was determined the facility failed to maintain the required automatic sprinkler system on one of four floors.

Findings include:

1. Observation on March 30, 2010, at 9:05 AM in the 3rd Floor Intensive Care Unit Equipment Storage Room, revealed speaker wire being supported by a sprinkler pipe.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:05 AM confirmed the speaker wire on sprinkler pipe.

2. Observation on March 30, 2010, at 9:15 AM in the 3rd Floor Soiled Utility Room, across from Room #354, revealed communication wire attached to a sprinkler pipe hanger.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 9:15 AM confirmed the wire attached to the sprinkler pipe hanger.

No Description Available

Tag No.: K0064

Based on observation and interview,the facility failed to maintain portable fire extinguishers in accordance with the regulations for two extinguishers, on one of six floors.

Findings include:

1. Observation on March 31, 2010, at 8:45 AM revealed that a trash can was blocking access to the fire extinguisher in the Ground Floor Snack Bar.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 8:45 AM confirmed the blocked extinguisher.

2. Observation on March 31, 2010, at 9:00 AM revealed that the "K" type fire extinguisher, located in the Ground Floor Snack Bar Kitchen, was missing an inspection for February 2010. In addition, the extinguisher lacked signage identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system.

Interview with the Facilities Coordinator and Boiler Operator on March 31, 2010, at 9:00 AM confirmed the missed inspection and lack of signage.

3. Observation on March 31, 2010, at 9:00 AM revealed that the fire extinguisher in the 1st Floor Mechanical Room, by the North Stair Tower, had not been inspected during February or March 2010.

Interview with the Director of Plant Operations on March 30, 2010, at 9:00 AM confirmed the fire extinguisher was not inspected during the last two (2) months.

4. Observation on March 31, 2010, at 9:47 AM revealed that the fire extinguisher in the Security Room had not been inspected during February or March 2010.

Interview with the Plant Operations Manager on March 31, 2010, at 9:47 AM confirmed the fire extinguisher was not inspected during the last two (2) months.

No Description Available

Tag No.: K0067

Based on observation and interview, the facility failed to maintain Heating, Ventilating, and Air Conditioning (HVAC) system ductwork through fire-rated walls in accordance with regulations, in two locations, on one of six floors.

Findings include:

1. Observation on March 29, 2010, at 2:40 PM revealed the facility could not verify that combination fire/smoke dampers exist in two HVAC ducts, which penetrated the 2-hour fire resistant common wall and smoke barrier wall, between the 01 and 03 Components, as viewed from the Main Building Security Office. The ducts appeared to have smoke dampers which were disconnected.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 2:40 PM confirmed the above deficiency.

No Description Available

Tag No.: K0069

Based on documentation review and interview, the facility failed to provide documentation reflecting that cooking facilities for the entire facility were protected in accordance with 9.2.3., 19.3.2.6, NFPA 96.

Findings include:

1. Document review on March 29, 2010, between 10:00 AM and 12:30 PM, revealed that the facility lacked documentation that monthly "quick checks" were being performed on the kitchen suppression system.

Interview with the Plant Operations Manager on March 29, 2010, at 12:30 PM confirmed monthly "quick checks" were not performed on the kitchen suppression system.

No Description Available

Tag No.: K0071

Based on observation and interview, it was determined that the facility failed to properly maintain the fire protection for trash chutes, incinerators and laundry chutes in one room.

Findings include:

Observation on March 30, 2010, at 2:15 PM revealed a six (6) inch pipe penetration of the ceiling assembly of the Laundry Chute Terminal Room.

Interview with the Chief Safety Officer and Electrician on March 30, 2010, at 2:15 PM confirmed the penetration.

No Description Available

Tag No.: K0076

Based on observation and interview, it was determined the facility failed to provide medical gas storage and administration areas in accordance with NFPA 101, 19.3.2.4 and NFPA 99, 1999 edition, in three (3) rooms on two (2) of six (6) floors.

Findings include:

1. Observation on March 30, 2010, at 8:43 AM revealed oxygen "E" cylinders were not segregated empty and full, two oxygen "E" cylinders were not secured, a light switch was less than 60 inches from the floor, the door did not close and latch into the frame and there were two large penetrations above the door, around pipes as viewed from the corridor.

Interview with the Plant Operations Manager on March 30, 2010, at 8:43 AM confirmed the Oxygen Storage Room deficiencies.

2. Observation on March 30, 2010, at 11:10 AM in the Respiratory Therapy Room revealed numerous Oxygen "H" cylinders being stored in the room. The room was being used as therapy/office space and was not rated for the storage of oxygen. The door was rated for 20 minutes, electrical outlets and switches were within five (5) feet of the floor surface. The room lacked required signage providing the minimum wording: CAUTION OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING. The sign must be conspicuously displayed and readable from a distance of 5 feet.

Interview with the Chief Nursing Officer and Electrician on March 30, 2010, at 11:10 AM confirmed oxygen was stored in the room.

3. Observation on March 30, 2010, at 1:37 PM revealed an unsecured oxygen "E" cylinder in the 3rd Floor OR #7.

Interview with the Plant Operations Manager on March 30, 2010, at 1:37 PM confirmed the unsecured oxygen "E" cylinder.

No Description Available

Tag No.: K0077

Based on observation and interview, the facility failed to maintain the piped-in medical gas system in one room of one floor.

Findings include:

Observation on March 29, 2010, at 2:15 PM, revealed the medical gas and vacuum lines in the ceiling in the 4th Floor Inpatient Dialysis required visible labels.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 2:15 PM confirmed the absence of visible labels.

No Description Available

Tag No.: K0078

Based on documentation review and interview, the facility failed to maintain relative humidity levels, in anesthetizing locations, in accordance with regulations.

Findings include:

1. Review of documentation on March 29, 2010, between 10:00 AM and 12:30 PM revealed that the relative humidity levels for the Operating Rooms and Cath Labs over the months of January, March, and December 2009 were less than 35% and as low as 15% at various times during the month.

Interview with the Director of Plant Operations on March 29, 2010, at 12:30 PM confirmed that relative humidity levels were not maintained at or above 35%.

No Description Available

Tag No.: K0130

28 Pa. Code § 103.4(3). FUNCTIONS

The governing body, with technical assistance and advice from the hospital staff, shall do the following: (3) Take all reasonable steps to conform to all applicable Federal, State and local laws and regulations. This REGULATION has not been met.

35 P.S. § 448.808. Issuance of license.

(a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met:

(2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered;

Based on observation and interview, it was determined the following item(s) did not conform to applicable Federal,State and local laws and regulations. The facility failed to provide adequate floor plans for the Licensure Survey.

Findings include:

Observation of floor plans on March 29-31, 2010, revealed the facility's floor plans did not indicate rated walls for storage, soiled utilities, medical gas, and shafts; did not differentiate between smoke and fire walls, and horizontal exits and exits were not clearly noted.

Interview with the Director of Plant Operations on March 31, 2010, at 11:30 AM confirmed the floor plans were not sufficient for the purpose of this survey.

No Description Available

Tag No.: K0140

Based on observation and interview, the facility failed to maintain medical gas alarm panels in one location, on one of four floors.

Findings include:

1. Observation on March 30, 2010, at 9:32 AM revealed that the medical gas alarm panel, located at the Ground Floor back Emergency Room Nurses' Station, was in alarm and silenced. The oxygen was in a low alarm, reading 13 PSIG. Interview with the Facilities Coordinator revealed that the panel had been malfunctioning and had been identified as needing repaired or replaced.

Interview with the Facilities Coordinator and Boiler Operator on March 30, 2010, at 9:32 AM confirmed the above medical gas panel deficiency.

No Description Available

Tag No.: K0144

Based on documentation review and interview, the facility failed to maintain the emergency generators which supplies emergency power for the entire building.

Findings include:

1. Review of documentation on March 29, 2010, between 10:00 AM and 12:30 PM, revealed that emergency generator #1 (Olympian) and emergency generator #3 (Onan) were not visually inspected weekly for 4 weeks, between March and April 2009.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 12:30 PM confirmed the missing visual inspections.

2. Review of documentation on March 29, 2010, between 10:00 AM and 12:30 PM, revealed the following emergency generator deficiencies, as identified by Premium Power Services, during annual load-bank testing:

a) Generator #1 (Olympian) - report dated 4/16/09, identified that the intake and exhaust louvers did not operate properly;
b) Generator #2 (Onan) - report dated 4/16/09, and another preventive maintenance report dated 11/12/09, identified that the engine temperature gauge was not functioning properly; the engine starting batteries needed to be replaced; and the engine block heater was imperative.

Interview with the Facilities Coordinator and Boiler Operator on March 29, 2010, at 12:30 PM confirmed the generator deficiencies above and the lack of documentation identifying corrective actions.

No Description Available

Tag No.: K0147

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and/or equipment on one of four floors.

Findings include:

1. Observation on March 29, 2010, at 3:05 PM revealed an open exposed electrical box from the removal of an EXIT sign, in the ceiling at the fire doors in the 3rd Floor Bridge.

Interview with the Chief Quality Officer and Electrician on March 29, 2010, at 3:05 PM confirmed the open electrical box.

2. Observation on March 30, 2010, at 9:55 AM revealed two open electrical Heating, Ventilating and Air Conditioning (HVAC) control boxes, on the 4th Floor Elevator Lobby by #9.

Interview with the Director of Plant Operations on March 30, 2010, at 9:55 AM confirmed that the above condition exists.

Means of Egress - General

Tag No.: K0211

Based on observation and interview, the facility failed to install Alcohol Based Hand Rub (ABHR) dispensers in accordance with the regulations, in one location on the 4th Floor.

Findings include:

1. Observation on March 30, 2010, at 9:20 AM revealed that an ABHR dispenser was installed over an electrical receptacle, on the 4th Floor in Patient Room 412.

Interview with the Director of Plant Operations on March 30, 2010, at 9:20 AM confirmed the ABHR dispenser location.