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Based on observations made during the survey of April 26, 2011, it has been determined that the facility did not maintain the fire resistive rating of all wall assemblies.

Findings include:

At 2:42 p.m., there were unsealed penetrations in the 1 hour wall partition which separated the main floor into two parts. The penetrations were caused by sections of conduit 1/2 to 1 inch in diameter used to allow a number of yellow an red wires to pass through the partition at unsealed lumen locations of the conduit.

Based on observations made on April 26, 2011, the facility failed to assure that rooms within the Type II (111) construction portion of the building were maintained to meet the fire resistance rating.

The finding include:

The IT room adjacent to the Patient Care wing nurse's station was examined at 10:51 a.m. on April 26, 2011. The construction plans for the facility show this particular room as requiring rated wall assemblies. The rating of the wall assembly in this room was not maintained as evidenced by several open holes in the wall along with lack of flanges around duct work penetrating the walls of this room.

Based on observations made on April 26, 2011, the facility failed to prevent the use of hold open devices that did not release when the door was pushed or pulled and failed to prevent the use of devices or objects that would impede the closing and latching of a corridor door.

The findings include:

Hold-open devices that release when the door is pushed or pulled shall be permitted per section 18.3.6.3.3 of the Life Safety Code.

1. The corridor door to the Chapel was examined and exercised at 11:18 a.m. on April 26, 2011. A kick-down door holder device was in use. When pushed the door holder did not retract upward to release and when pulled forward the door holder impeded the door from closing by "digging" into the carpet. This type of door stop is not acceptable as a hold open device.

Doors shall be provided with positive latching hardware. Roller latches shall be prohibited per section 18.3.6.3.2 of the Life Safety Code. There shall be no impediment to interfere with the door closing and latching.

2. The corridor door into the OB registration office from the OB corridor system was exercised at 3:10 p.m. on April 26, 2011. A foam door sweep which slides across the bottom of the door to prevent air movement was in place. When the door was exercised the door sweep moved with the swing of the door and inhibited the door from closing and latching by sliding out against the door frame. Note: The sweep was removed from the bottom of the door after the observation was made and confirmed by the surveyor while on-site.
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Based on observations made on April 27, 2011, the facility failed to maintain the one-hour fire resistance rating of smoke barriers.

The findings include:

1. The combination fire/smoke barrier located above the fire doors in the corridor between the Service Materials corridor and the Radiology corridor was examined at 8:40 a.m. on April 27, 2011. Fire rated caulking sealing a large conduit being used as a pass through for wiring had deteriorated in one of the large conduit and another conduit had a crack appearing in it. Note: Fire rated caulk was applied to seal the open area left by the deterioration and also to seal the crack after the observation was made and confirmed by the surveyor while on-site.

2. The east wall smoke barrier above the ceiling tiles of the women's restroom adjacent to the mail room was examined at 9:58 a.m. on April 27, 2011. An open faced conduit was being used as a pass through for red and white wiring. Note: Fire rated caulk was applied to the open face of the conduit to seal it after the observation was made and confirmed by the surveyor while on-site.

3. The east wall smoke barrier above the ceiling tiles of the Library was examined at 10:18 a.m. on April 27, 2011. An open faced conduit was being used as a pass through for data wiring. Note: Fire rated caulk was applied to the open face of the conduit to seal it after the observation was made and confirmed by the surveyor while on-site.

4. The east wall smoke barrier above the ceiling tiles of the women's restroom opposite the Laboratory registration counter was examined at 11:00 a.m. on April 27, 2011. An open faced conduit was being used as a pass through for red and white wiring. Note: Fire rated caulk was applied to the open face of the conduit to seal it after the observation was made and confirmed by the surveyor while on-site.

5. The smoke barrier wall between the kitchen area and the serving/cafeteria area was examined at 11:10 a.m. on April 27, 2011. The barrier above the ceiling tiles by the north communicating door had three open faced conduit with two of those being used as a pass through for blue wiring. Additionally the wall area around an electrical conduit penetrating this barrier was not completely sealed.

6. The smoke barrier wall above the ceiling tiles between the Laboratory reception desk and the Laboratory itself was examined at 11:39 a.m. on April 27, 2011. An open faced conduit was being used as a pass through for wiring. Note: Fire rated caulk was applied to the open face of the conduit to seal it after the observation was made and confirmed by the surveyor while on-site.

7. The smoke barrier wall above the ceiling tiles of the 24 hour register desk/monitoring room was examined at 11:59 a.m. on April 27, 2011. A seam left at the joining point of two layers of sheet rock protecting the smoke barrier had not been fire taped or sealed.

Based on surveyor observations of April 26, 2011, it was determined there was an acceptable means of egress identified but was not kept totally free and clear.

Findings include:

In accordance with NFPA 38.2.1.1, all means of egress shall be in accordance with Chapter 7 and this chapter.

At 2:51 p.m., the surveyor inspected the other side of the building opposite from the Sleep Medicine Center. In the room was a conference table and a chair which was placed against an exit door. The door was identified as an exit by an exit sign above the door.

Based on observations made on April 26, 2011, the facility failed to provide for a hard surface path from an exit discharge to the public way.

The findings include:

There shall be provided a hard surface path from the exit discharge to the public way or area of refuge in climates where weather such as snow or ice or heavy rain may hinder evacuation across lawn or soil surfaces per section 7.7.1 of the Life Safety Code and interpretations from the Centers for Medicare and Medicaid Services (CMS).

An exit discharge to the east from the SCU wing was observed at 10:10 a.m. on April 26, 2011, to lead to a "healing garden" area. The healing garden area was basically a patio area surrounded by intermittent brick walls. No hard surface path was in place from this patio area to the public way.

Based on review of the generator test logs and other maintenance logs on April 25, 2011, the facility failed to maintain a log of the monthly and annual testing of the battery-powered emergency lights in the emergency generator room and any Anesthetizing locations.

The findings include:

The Level 1 or Level 2 EPS equipment (emergency generator) location shall be provided with battery-powered emergency lighting per section 3-4.2.2.2(b)5 of NFPA 99, 1999 Edition and section 5-3.1 of NFPA 110, 1999 Edition. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch. In accordance with 7.9.3 of the Life Safety Code a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

1. The room housing the generator and the transfer switches have battery-powered emergency lights. No documentation that these lights were tested on a monthly or annual basis were available after review of the generator and other maintenance logs on April 25, 2011.

One or more battery-powered emergency lighting units shall be provided in any Anesthetizing location per section 3-3.2.1.2(a)5e of NFPA 99, 1999 Edition and Article 517-63 of NFPA 70, 1999 Edition. In accordance with 7.9.3 of the Life Safety Code a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

2. Each of the three operating rooms have one ceiling light fixture that is on a battery-powered emergency system as confirmed by the visual indication of a red charging lamp in the fixtures. No documentation that these lights were tested on a monthly or annual basis were available after review of maintenance logs on April 25, 2011.

Based on observations which were made on April 27, 2011, it was determined that the facility did not ensure that all exit signs were properly illuminated.

Findings include:

In accordance with 39.2.10 Marking of Means of Egress,
means of egress shall have signs in accordance with Section 7.10.

1. At 8:01 a.m., surveyor observed that there was an exit sign above the main entrance door to the physical therapy clinic. There was no illumination inside the exit sign.

2. At approximately 8:30 a.m., a second exit sign was not illuminated above a door opening directly to the outside from the vacated space that previously contained a exercise and workout business.

Based on review of the fire drill report forms on April 25, 2011, the facility failed to assure that fire drills were held on each shift at least quarterly and that the fire alarm system was activated on fire drills held between the hours of 6 a.m. and 9 p.m.

The findings include:

1. The fire drill reports for the facility were reviewed on April 25, 2011. No documentation was available verifying that a fire drill had been held on the 7 a.m. to 3 p.m. shift during the fourth quarter (October, November, December) of 2010.

Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions per section 18.7.1.2 of the Life Safety Code with the exception that when drills are conducted between 9:00 p.m. and 6:00 a.m. a coded announcement shall be permitted to be used instead of audible alarms.

2. The fire drill conducted on June 5, 2010 at 4:15 p.m. stated that "The alarm was not activated. This was by passed in lieu of extinguishing operations. The alarm should have been activated at the south entrance if possible. This would have alerted anyone present that there was a fire event in that location". The facility did recognize that the fire alarm system should have been activated, but was not during the drill.

3. The fire drill conducted on July 15, 2010 at 6:40 a.m. stated that "Activation of the fire alarm in this case was not necessary as a full activation of the incident command was executed." Although the incident command system was activated, the fire alarm system should also have been activated to provide notification to staff and occupants.

As a result of the life safety code inspection on April 26, 2011, it was determined that not all requirements for the fire alarm system had been followed.

Findings include:

In accordance with NFPA 101 Section 38.3.4.1 General, a fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 50 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 300 or more total occupants.

However, if the fire alarm is in place it must be funcitional per NFPA 101 Section 4.6.12.2 existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

During a tour of the building at approximately 2:50 p.m., it was observed that the building was equipped with a fire alarm system. When the surveyor inquired when the last time the system was tested, no information was provided if a licensed contract service had tested the system. On May 3, 2011, a phone discussion was held with staff member A which confirmed that the fire alarm system had not been tested or serviced in the last 12 months.

As a result of the life safety code inspection on April 27, 2011, it was determined that not all requirements for the fire alarm system had been followed.

Findings include:

In accordance with NFPA 101 Section 39.3.4.1 General,
a fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

However, if the fire alarm is in place it must be funcitional per NFPA 101 Section 4.6.12.2 existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

During a tour of the building at approximately 2:30 p.m., it was observed that the facility was equipped with a fire alarm system.
When surveyor inquired when the last time the system was tested, no information was provided if a licensed contract service had tested the system in the last year.

Since the time of this onsite survey, a contractor has been scheduled to do testing and inspection of the fire alarm system. In addition, in a telephone call with fire alarm service personel at 2:20 p.m. on May 3, 2011, it was confirmed that the last record of service for the fire alarm system was in 2001.

Based on discussions with staff on April 27, 2011, it was determined that not all requirements for the fire alarm system had been followed.

Findings include:

In accordance with NFPA 101 Section 39.3.4.1 General,
a fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

However, if the fire alarm is in place it must be funcitional per NFPA 101 Section 4.6.12.2 existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

At approximately 10:00 a.m., the spaces of the clinic where inspected by the surveyor. An inquiry was made if any records were available for the testing of the fire alarm system the building. It was understood that the business manager of the clinic had that information. On May 3, 2011, a phone discussion was held with staff member A which confirmed that the fire alarm system had not been tested or serviced in the last 12 months.

Based on observations made on April 26, 2011, the facility failed to maintain components of the automatic sprinkler system.

The findings include:

Sprinklers shall be free of corrosion, foreign material, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall) per section 2-2.1.1 of NFPA 25, 1998 Edition.

1. A sprinkler head located in the serving area of the cafe/dining suite was coated with foreign material as observed at 9:18 a.m. on April 26, 2011. Note: The sprinkler was removed and replaced after the observation was made and confirmed by the surveyor while on-site.

The liquid in bulb-type sprinklers shall be color coded in accordance with Table 3-2.5.1 of NFPA 13, 1999 Edition. Ordinary temperature rated sprinklers shall have either orange or red colored bulbs.

2. The bathroom of OB room 126 was examined at 3:00 p.m. on April 26, 2011. The glass bulb in the ordinary temperature rated sprinkler in this bathroom had changed color from red to white indicating that the sprinkler may not react at its rated temperature.

Based on observations made on 04/27/2011, the facility failed to ensure that each portable fire extinguisher was inspected monthly.

The findings include:

In accordance with NFPA 101 and Section 39.3.5 Extinguishment Requirements, portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1. (See also Section 39.4.)

In accordance with NFPA 101and Section 9.7.4.1,
where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Personnel shall make monthly inspections of the fire extinguishers and shall keep records that show the date the inspection was performed and the initials of the person completing the inspection per sections 4-3.4.1, 4-3.4.2 and 4-3.4.3 of NFPA 10, 1998 Edition.

A portable fire extinguisher was examined during a tour of the clinic. The extinguisher did have an inspection tag showing annual inspection had been done in the past year. However, there was no record of monthly inspections of the fire extinguisher since the annual inspection.

Based on observations made on April 27, 2011, the facility failed to ensure that each portable fire extinguisher was inspected monthly.

The findings include:

In accordance with NFPA 101 and Section 38.3.5 Extinguishment Requirements, portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1. (See also Section 38.4.)

In accordance with NFPA 101and Section 9.7.4.1,
where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Personnel shall make monthly inspections of the fire extinguishers and shall keep records that show the date the inspection was performed and the initials of the person completing the inspection per sections 4-3.4.1, 4-3.4.2 and 4-3.4.3 of NFPA 10, 1998 Edition.

At approximately 3:00 p.m., a portable fire extinguisher was examined in the Sleep Medicine Center. The extinguisher did have an inspection tag showing annual inspection being done. However, there is no record of monthly inspection of the fire extinguisher since the annual inspection date.

Based on observations made on April 27, 2011, the facility failed to ensure that each portable fire extinguisher was inspected monthly.

The findings include:

In accordance with NFPA 101 and Section 39.3.5 Extinguishment Requirements, portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1. (See also Section 39.4.)

In accordance with NFPA 101and Section 9.7.4.1,
where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Personnel shall make monthly inspections of the fire extinguishers and shall keep records that show the date the inspection was performed and the initials of the person completing the inspection per sections 4-3.4.1, 4-3.4.2 and 4-3.4.3 of NFPA 10, 1998 Edition.


Personnel shall make monthly inspections of the fire extinguishers and shall keep records that show the date the inspection was performed and the initials of the person completing the inspection per sections 4-3.4.1, 4-3.4.2 and 4-3.4.3 of NFPA 10, 1998 Edition.

A portable fire extinguisher was examined on the main level in the corridor which serves the "Dexascan" treatment room. The extinguisher did have an inspection tag showing annual inspection being done in September of 2010. However, there was no record of monthly inspections of the fire extinguisher since the annual inspection.

Based on observations which were made on April 27, 2011, it was determined that the facility did not ensure that portable fire extinguishers were always maintained in accordance with all the standards of NFPA 10.

Findings include:

In accordance with NFPA 101 and Section 39.3.5 Extinguishment Requirements, portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1. (See also Section 39.4.)

In accordance with NFPA 101and Section 9.7.4.1,
where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

In accordance with 1-6.7 and 1-6.10 of NFPA 10, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

Personnel shall make monthly inspections of the fire extinguishers and shall keep records that show the date the inspection was performed and the initials of the person completing the inspection per sections 4-3.4.1, 4-3.4.2 and 4-3.4.3 of NFPA 10, 1998 Edition.

1. While making survey observations in the building between 8:00 a.m. and 9 :00 a.m., a fire extinguisher was examined in the vacated space of a former business (gym). The fire extinguisher was sitting "free standing" and unsecured on a counter top.

2. A portable fire extinguisher was examined in the space occupied by Physical Therapy Clinic. The extinguisher did have an inspection tag showing an annual inspection being done in November of 2010. However, there is no record of monthly inspections of the fire extinguisher since the time of the annual inspection.

Based on observations made on April 26, 2011, the facility failed to prevent the use of a portable heater in a treatment area of a healthcare occupancy.

The findings include:

The Emergency Room suite was toured at 1:38 p.m. on April 26, 2011. The nurse's station was considered as part of the healthcare and treatment area of the suite as it was not separated by walls or doors so as to be considered a non-sleeping staff or employee area. A "Dayton" brand portable heater was in use under the counter at the nurse's station. Note: The portable heater was removed from the suite after the observation was made and confirmed by the surveyor while on-site.

Based on observations made on April 26, 2011, the facility failed to assure that all curtains, including cubicle curtains, were flame resistant in accordance with the standards of NFPA 701, 1999 Edition.

The findings include:

An alcove across from patient room 116 had cubicle curtains in place as observed at 11:03 a.m. on April 26, 2011. Upon examination there was no label, tag or other documentation verifying that the cubicle curtains met the flame resistant standards of NFPA 701.

Based on observations made on April 26, 2011, the facility failed to post a "No Smoking" sign within 50 feet of the access/egress point to the heliport.

The findings include:

NFPA 418, the Standard for Heliports,1995 Edition, is referenced within the Life Safety Code as a mandatory requirement under section 2.1.1 and shall be considered part of the requirements of the Life Safety Code. No smoking shall be permitted within 50 feet of the landing pad edge per section 2-5 of NFPA 418. No smoking signs shall be erected at access/egress points to the heliport.

1. The facility has a heliport landing pad to the west of the Emergency Room ambulance canopy. The sidewalk and pathway to this heliport pad did not have a "No Smoking" sign posted at it within 50 feet of the pad.

NFPA 30, the Flammable and Combustible Liquids Code, 1996 Edition, is referenced within the Life Safety Code as a mandatory requirement under section 2.1.1 and shall be considered part of the requirements of the Life Safety Code. In tank storage locations where flammable vapors could be present, precautions shall be taken to prevent ignition by eliminating or controlling sources of ignition per section 2-7 of NFPA 30. Sources of ignition can include open flames, lightning, smoking, cutting and welding, hot surfaces, frictional heat, sparks (static, electrical, and mechanical), spontaneous ignition, chemical and physicochemical reactions, and radiant heat. Acceptable means of eliminating smoking as an ignition source is by posting of "No Smoking" signs or other signs warning of the ignition hazards associated with tank storage of flammable or combustible liquids.

2. A diesel storage tank was located on the west side of the campus serving as the fuel source for the emergency generator as observed at 12:56 p.m. on April 26, 2011. There were no precautionary signs such as "No Smoking" or other language on the tank to eliminate or warn of the use of ignition sources for vapors present in the area of the tank.

Based on observations made on April 27, 2011, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition, NFPA 99, 1999 Edition, or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

In accordance with NFPA 101 and Section 38.5.1, utilities shall comply with the provisions of Section 9.1. Further, Section 9.1.2 Electric states that electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70, sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 and interpretations from CMS.

In accordance with Article 370.28(c) of NFPA 70 (1999 Edition) all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Article 250-110.

1. At 8:32 a.m., there was a brown extension cord in use on the floor behind the counter located in the vacated space of a former business (gym).

2. At 9:05 a.m. in the space called the "Community Center", a fractured electrical outlet cover in one corner of that room needed to be replaced.

Surveyor observations were made at the facility on April 26, 2011. The facility failed to ensure the electrical system and its components were always being maintained in accordance with NFPA 70.

Findings include:

In accordance with NFPA 101 and Section 38.5.1, utilities shall comply with the provisions of Section 9.1. Further, Section 9.1.2 Electric states that electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

In accordance with Article 370.28(c) of NFPA 70 (1999 Edition) all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Article 250-110.

In accordance with Article 110-13(a) of NFPA 70 (1999 edition) electrical equipment shall be firmly secured to the surface on which it is mounted.

In accordance with Article 110-26 of the NFPA 70 (1999 Edition) requires that "sufficient access and working space (a minimum clearance of 3 feet) be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment."


1. At 2:34 p.m. in the office of the Sleep Medicine Center, the electrical outlets and wiring were inspected. Above a desktop at the wall, several blue computer wires had not been secured and covered with the appropriate electrical cover plate.


2. At 2:33 p.m.. in the office of the Sleep Medicine Center, the electrical outlets and wiring was inspected. Underneath a desktop a power strip was plugged into an electrical outlet. The power strip was hanging in the air and had not been properly secured to the wall or the desk.

3. At 2:51 p.m. in that part of the building which is not the Sleep Medicine Center, in a conference room two folding tables had been placed against an electrical panel which blocked access to the electrical panel.

Based on observations made on April 26 and 27, 2011, the facility failed to maintain the electrical system and/or its components in accordance with the National Electrical Code, NFPA 70, 1999 Edition.

The findings include:

Unless specifically permitted in Section 400-7, flexible cords (including extension cords) and cables shall not be used as a substitute for the fixed wiring of a structure per Article 400-8 of NFPA 70. Extension cords may be used for temporary wiring in accordance with Articles 305-4(b) and 305-4(c) of NFPA 70.

1. The soiled utility room across from OB room 125 was examined at 3:06 a.m. on April 26, 2011. Two refrigerators were in use in this room. Each refrigerator had an extension cord supplying power to it in lieu of direct connection to the fixed wiring (receptacles) of the building.

Ground Fault Circuit Interrupter (GFCI) receptacles shall be listed in accordance with Articles 110-2 and 110-3 of NFPA 70 and shall have trip times per their listing under UL 498 standards.

2. The GFCI receptacle by the sink in the sub sterile room between operating rooms 1 and 2 was exercised at 7:14 a.m. on April 27, 2011. The receptacle did not break current when the test button was pushed.

3. The GFCI receptacle in the staff break room across from the north surgical recovery beds 1 and 2 was exercised at 7:26 a.m. on April 27, 2011. The receptacle did not break current when the test button was pushed.

Based on observations made during the survey of April 26, 2011, it has been determined that the facility did not maintain the fire resistive rating of all wall assemblies.

Findings include:

At 2:42 p.m., there were unsealed penetrations in the 1 hour wall partition which separated the main floor into two parts. The penetrations were caused by sections of conduit 1/2 to 1 inch in diameter used to allow a number of yellow an red wires to pass through the partition at unsealed lumen locations of the conduit.

Based on observations made on April 26, 2011, the facility failed to assure that rooms within the Type II (111) construction portion of the building were maintained to meet the fire resistance rating.

The finding include:

The IT room adjacent to the Patient Care wing nurse's station was examined at 10:51 a.m. on April 26, 2011. The construction plans for the facility show this particular room as requiring rated wall assemblies. The rating of the wall assembly in this room was not maintained as evidenced by several open holes in the wall along with lack of flanges around duct work penetrating the walls of this room.

Based on observations made on April 26, 2011, the facility failed to prevent the use of hold open devices that did not release when the door was pushed or pulled and failed to prevent the use of devices or objects that would impede the closing and latching of a corridor door.

The findings include:

Hold-open devices that release when the door is pushed or pulled shall be permitted per section 18.3.6.3.3 of the Life Safety Code.

1. The corridor door to the Chapel was examined and exercised at 11:18 a.m. on April 26, 2011. A kick-down door holder device was in use. When pushed the door holder did not retract upward to release and when pulled forward the door holder impeded the door from closing by "digging" into the carpet. This type of door stop is not acceptable as a hold open device.

Doors shall be provided with positive latching hardware. Roller latches shall be prohibited per section 18.3.6.3.2 of the Life Safety Code. There shall be no impediment to interfere with the door closing and latching.

2. The corridor door into the OB registration office from the OB corridor system was exercised at 3:10 p.m. on April 26, 2011. A foam door sweep which slides across the bottom of the door to prevent air movement was in place. When the door was exercised the door sweep moved with the swing of the door and inhibited the door from closing and latching by sliding out against the door frame. Note: The sweep was removed from the bottom of the door after the observation was made and confirmed by the surveyor while on-site.
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Based on observations made on April 27, 2011, the facility failed to maintain the one-hour fire resistance rating of smoke barriers.

The findings include:

1. The combination fire/smoke barrier located above the fire doors in the corridor between the Service Materials corridor and the Radiology corridor was examined at 8:40 a.m. on April 27, 2011. Fire rated caulking sealing a large conduit being used as a pass through for wiring had deteriorated in one of the large conduit and another conduit had a crack appearing in it. Note: Fire rated caulk was applied to seal the open area left by the deterioration and also to seal the crack after the observation was made and confirmed by the surveyor while on-site.

2. The east wall smoke barrier above the ceiling tiles of the women's restroom adjacent to the mail room was examined at 9:58 a.m. on April 27, 2011. An open faced conduit was being used as a pass through for red and white wiring. Note: Fire rated caulk was applied to the open face of the conduit to seal it after the observation was made and confirmed by the surveyor while on-site.

3. The east wall smoke barrier above the ceiling tiles of the Library was examined at 10:18 a.m. on April 27, 2011. An open faced conduit was being used as a pass through for data wiring. Note: Fire rated caulk was applied to the open face of the conduit to seal it after the observation was made and confirmed by the surveyor while on-site.

4. The east wall smoke barrier above the ceiling tiles of the women's restroom opposite the Laboratory registration counter was examined at 11:00 a.m. on April 27, 2011. An open faced conduit was being used as a pass through for red and white wiring. Note: Fire rated caulk was applied to the open face of the conduit to seal it after the observation was made and confirmed by the surveyor while on-site.

5. The smoke barrier wall between the kitchen area and the serving/cafeteria area was examined at 11:10 a.m. on April 27, 2011. The barrier above the ceiling tiles by the north communicating door had three open faced conduit with two of those being used as a pass through for blue wiring. Additionally the wall area around an electrical conduit penetrating this barrier was not completely sealed.

6. The smoke barrier wall above the ceiling tiles between the Laboratory reception desk and the Laboratory itself was examined at 11:39 a.m. on April 27, 2011. An open faced conduit was being used as a pass through for wiring. Note: Fire rated caulk was applied to the open face of the conduit to seal it after the observation was made and confirmed by the surveyor while on-site.

7. The smoke barrier wall above the ceiling tiles of the 24 hour register desk/monitoring room was examined at 11:59 a.m. on April 27, 2011. A seam left at the joining point of two layers of sheet rock protecting the smoke barrier had not been fire taped or sealed.

Based on surveyor observations of April 26, 2011, it was determined there was an acceptable means of egress identified but was not kept totally free and clear.

Findings include:

In accordance with NFPA 38.2.1.1, all means of egress shall be in accordance with Chapter 7 and this chapter.

At 2:51 p.m., the surveyor inspected the other side of the building opposite from the Sleep Medicine Center. In the room was a conference table and a chair which was placed against an exit door. The door was identified as an exit by an exit sign above the door.

Based on observations made on April 26, 2011, the facility failed to provide for a hard surface path from an exit discharge to the public way.

The findings include:

There shall be provided a hard surface path from the exit discharge to the public way or area of refuge in climates where weather such as snow or ice or heavy rain may hinder evacuation across lawn or soil surfaces per section 7.7.1 of the Life Safety Code and interpretations from the Centers for Medicare and Medicaid Services (CMS).

An exit discharge to the east from the SCU wing was observed at 10:10 a.m. on April 26, 2011, to lead to a "healing garden" area. The healing garden area was basically a patio area surrounded by intermittent brick walls. No hard surface path was in place from this patio area to the public way.

Based on review of the generator test logs and other maintenance logs on April 25, 2011, the facility failed to maintain a log of the monthly and annual testing of the battery-powered emergency lights in the emergency generator room and any Anesthetizing locations.

The findings include:

The Level 1 or Level 2 EPS equipment (emergency generator) location shall be provided with battery-powered emergency lighting per section 3-4.2.2.2(b)5 of NFPA 99, 1999 Edition and section 5-3.1 of NFPA 110, 1999 Edition. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch. In accordance with 7.9.3 of the Life Safety Code a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

1. The room housing the generator and the transfer switches have battery-powered emergency lights. No documentation that these lights were tested on a monthly or annual basis were available after review of the generator and other maintenance logs on April 25, 2011.

One or more battery-powered emergency lighting units shall be provided in any Anesthetizing location per section 3-3.2.1.2(a)5e of NFPA 99, 1999 Edition and Article 517-63 of NFPA 70, 1999 Edition. In accordance with 7.9.3 of the Life Safety Code a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

2. Each of the three operating rooms have one ceiling light fixture that is on a battery-powered emergency system as confirmed by the visual indication of a red charging lamp in the fixtures. No documentation that these lights were tested on a monthly or annual basis were available after review of maintenance logs on April 25, 2011.

Based on observations which were made on April 27, 2011, it was determined that the facility did not ensure that all exit signs were properly illuminated.

Findings include:

In accordance with 39.2.10 Marking of Means of Egress,
means of egress shall have signs in accordance with Section 7.10.

1. At 8:01 a.m., surveyor observed that there was an exit sign above the main entrance door to the physical therapy clinic. There was no illumination inside the exit sign.

2. At approximately 8:30 a.m., a second exit sign was not illuminated above a door opening directly to the outside from the vacated space that previously contained a exercise and workout business.

Based on review of the fire drill report forms on April 25, 2011, the facility failed to assure that fire drills were held on each shift at least quarterly and that the fire alarm system was activated on fire drills held between the hours of 6 a.m. and 9 p.m.

The findings include:

1. The fire drill reports for the facility were reviewed on April 25, 2011. No documentation was available verifying that a fire drill had been held on the 7 a.m. to 3 p.m. shift during the fourth quarter (October, November, December) of 2010.

Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions per section 18.7.1.2 of the Life Safety Code with the exception that when drills are conducted between 9:00 p.m. and 6:00 a.m. a coded announcement shall be permitted to be used instead of audible alarms.

2. The fire drill conducted on June 5, 2010 at 4:15 p.m. stated that "The alarm was not activated. This was by passed in lieu of extinguishing operations. The alarm should have been activated at the south entrance if possible. This would have alerted anyone present that there was a fire event in that location". The facility did recognize that the fire alarm system should have been activated, but was not during the drill.

3. The fire drill conducted on July 15, 2010 at 6:40 a.m. stated that "Activation of the fire alarm in this case was not necessary as a full activation of the incident command was executed." Although the incident command system was activated, the fire alarm system should also have been activated to provide notification to staff and occupants.

As a result of the life safety code inspection on April 26, 2011, it was determined that not all requirements for the fire alarm system had been followed.

Findings include:

In accordance with NFPA 101 Section 38.3.4.1 General, a fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 50 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 300 or more total occupants.

However, if the fire alarm is in place it must be funcitional per NFPA 101 Section 4.6.12.2 existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

During a tour of the building at approximately 2:50 p.m., it was observed that the building was equipped with a fire alarm system. When the surveyor inquired when the last time the system was tested, no information was provided if a licensed contract service had tested the system. On May 3, 2011, a phone discussion was held with staff member A which confirmed that the fire alarm system had not been tested or serviced in the last 12 months.

As a result of the life safety code inspection on April 27, 2011, it was determined that not all requirements for the fire alarm system had been followed.

Findings include:

In accordance with NFPA 101 Section 39.3.4.1 General,
a fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

However, if the fire alarm is in place it must be funcitional per NFPA 101 Section 4.6.12.2 existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

During a tour of the building at approximately 2:30 p.m., it was observed that the facility was equipped with a fire alarm system.
When surveyor inquired when the last time the system was tested, no information was provided if a licensed contract service had tested the system in the last year.

Since the time of this onsite survey, a contractor has been scheduled to do testing and inspection of the fire alarm system. In addition, in a telephone call with fire alarm service personel at 2:20 p.m. on May 3, 2011, it was confirmed that the last record of service for the fire alarm system was in 2001.

Based on discussions with staff on April 27, 2011, it was determined that not all requirements for the fire alarm system had been followed.

Findings include:

In accordance with NFPA 101 Section 39.3.4.1 General,
a fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

However, if the fire alarm is in place it must be funcitional per NFPA 101 Section 4.6.12.2 existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

At approximately 10:00 a.m., the spaces of the clinic where inspected by the surveyor. An inquiry was made if any records were available for the testing of the fire alarm system the building. It was understood that the business manager of the clinic had that information. On May 3, 2011, a phone discussion was held with staff member A which confirmed that the fire alarm system had not been tested or serviced in the last 12 months.

Based on observations made on April 26, 2011, the facility failed to maintain components of the automatic sprinkler system.

The findings include:

Sprinklers shall be free of corrosion, foreign material, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall) per section 2-2.1.1 of NFPA 25, 1998 Edition.

1. A sprinkler head located in the serving area of the cafe/dining suite was coated with foreign material as observed at 9:18 a.m. on April 26, 2011. Note: The sprinkler was removed and replaced after the observation was made and confirmed by the surveyor while on-site.

The liquid in bulb-type sprinklers shall be color coded in accordance with Table 3-2.5.1 of NFPA 13, 1999 Edition. Ordinary temperature rated sprinklers shall have either orange or red colored bulbs.

2. The bathroom of OB room 126 was examined at 3:00 p.m. on April 26, 2011. The glass bulb in the ordinary temperature rated sprinkler in this bathroom had changed color from red to white indicating that the sprinkler may not react at its rated temperature.

Based on observations made on 04/27/2011, the facility failed to ensure that each portable fire extinguisher was inspected monthly.

The findings include:

In accordance with NFPA 101 and Section 39.3.5 Extinguishment Requirements, portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1. (See also Section 39.4.)

In accordance with NFPA 101and Section 9.7.4.1,
where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Personnel shall make monthly inspections of the fire extinguishers and shall keep records that show the date the inspection was performed and the initials of the person completing the inspection per sections 4-3.4.1, 4-3.4.2 and 4-3.4.3 of NFPA 10, 1998 Edition.

A portable fire extinguisher was examined during a tour of the clinic. The extinguisher did have an inspection tag showing annual inspection had been done in the past year. However, there was no record of monthly inspections of the fire extinguisher since the annual inspection.

Based on observations made on April 27, 2011, the facility failed to ensure that each portable fire extinguisher was inspected monthly.

The findings include:

In accordance with NFPA 101 and Section 38.3.5 Extinguishment Requirements, portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1. (See also Section 38.4.)

In accordance with NFPA 101and Section 9.7.4.1,
where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Personnel shall make monthly inspections of the fire extinguishers and shall keep records that show the date the inspection was performed and the initials of the person completing the inspection per sections 4-3.4.1, 4-3.4.2 and 4-3.4.3 of NFPA 10, 1998 Edition.

At approximately 3:00 p.m., a portable fire extinguisher was examined in the Sleep Medicine Center. The extinguisher did have an inspection tag showing annual inspection being done. However, there is no record of monthly inspection of the fire extinguisher since the annual inspection date.

Based on observations made on April 27, 2011, the facility failed to ensure that each portable fire extinguisher was inspected monthly.

The findings include:

In accordance with NFPA 101 and Section 39.3.5 Extinguishment Requirements, portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1. (See also Section 39.4.)

In accordance with NFPA 101and Section 9.7.4.1,
where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Personnel shall make monthly inspections of the fire extinguishers and shall keep records that show the date the inspection was performed and the initials of the person completing the inspection per sections 4-3.4.1, 4-3.4.2 and 4-3.4.3 of NFPA 10, 1998 Edition.


Personnel shall make monthly inspections of the fire extinguishers and shall keep records that show the date the inspection was performed and the initials of the person completing the inspection per sections 4-3.4.1, 4-3.4.2 and 4-3.4.3 of NFPA 10, 1998 Edition.

A portable fire extinguisher was examined on the main level in the corridor which serves the "Dexascan" treatment room. The extinguisher did have an inspection tag showing annual inspection being done in September of 2010. However, there was no record of monthly inspections of the fire extinguisher since the annual inspection.

Based on observations which were made on April 27, 2011, it was determined that the facility did not ensure that portable fire extinguishers were always maintained in accordance with all the standards of NFPA 10.

Findings include:

In accordance with NFPA 101 and Section 39.3.5 Extinguishment Requirements, portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1. (See also Section 39.4.)

In accordance with NFPA 101and Section 9.7.4.1,
where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

In accordance with 1-6.7 and 1-6.10 of NFPA 10, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

Personnel shall make monthly inspections of the fire extinguishers and shall keep records that show the date the inspection was performed and the initials of the person completing the inspection per sections 4-3.4.1, 4-3.4.2 and 4-3.4.3 of NFPA 10, 1998 Edition.

1. While making survey observations in the building between 8:00 a.m. and 9 :00 a.m., a fire extinguisher was examined in the vacated space of a former business (gym). The fire extinguisher was sitting "free standing" and unsecured on a counter top.

2. A portable fire extinguisher was examined in the space occupied by Physical Therapy Clinic. The extinguisher did have an inspection tag showing an annual inspection being done in November of 2010. However, there is no record of monthly inspections of the fire extinguisher since the time of the annual inspection.

Based on observations made on April 26, 2011, the facility failed to prevent the use of a portable heater in a treatment area of a healthcare occupancy.

The findings include:

The Emergency Room suite was toured at 1:38 p.m. on April 26, 2011. The nurse's station was considered as part of the healthcare and treatment area of the suite as it was not separated by walls or doors so as to be considered a non-sleeping staff or employee area. A "Dayton" brand portable heater was in use under the counter at the nurse's station. Note: The portable heater was removed from the suite after the observation was made and confirmed by the surveyor while on-site.

Based on observations made on April 26, 2011, the facility failed to assure that all curtains, including cubicle curtains, were flame resistant in accordance with the standards of NFPA 701, 1999 Edition.

The findings include:

An alcove across from patient room 116 had cubicle curtains in place as observed at 11:03 a.m. on April 26, 2011. Upon examination there was no label, tag or other documentation verifying that the cubicle curtains met the flame resistant standards of NFPA 701.

Based on observations made on April 26, 2011, the facility failed to post a "No Smoking" sign within 50 feet of the access/egress point to the heliport.

The findings include:

NFPA 418, the Standard for Heliports,1995 Edition, is referenced within the Life Safety Code as a mandatory requirement under section 2.1.1 and shall be considered part of the requirements of the Life Safety Code. No smoking shall be permitted within 50 feet of the landing pad edge per section 2-5 of NFPA 418. No smoking signs shall be erected at access/egress points to the heliport.

1. The facility has a heliport landing pad to the west of the Emergency Room ambulance canopy. The sidewalk and pathway to this heliport pad did not have a "No Smoking" sign posted at it within 50 feet of the pad.

NFPA 30, the Flammable and Combustible Liquids Code, 1996 Edition, is referenced within the Life Safety Code as a mandatory requirement under section 2.1.1 and shall be considered part of the requirements of the Life Safety Code. In tank storage locations where flammable vapors could be present, precautions shall be taken to prevent ignition by eliminating or controlling sources of ignition per section 2-7 of NFPA 30. Sources of ignition can include open flames, lightning, smoking, cutting and welding, hot surfaces, frictional heat, sparks (static, electrical, and mechanical), spontaneous ignition, chemical and physicochemical reactions, and radiant heat. Acceptable means of eliminating smoking as an ignition source is by posting of "No Smoking" signs or other signs warning of the ignition hazards associated with tank storage of flammable or combustible liquids.

2. A diesel storage tank was located on the west side of the campus serving as the fuel source for the emergency generator as observed at 12:56 p.m. on April 26, 2011. There were no precautionary signs such as "No Smoking" or other language on the tank to eliminate or warn of the use of ignition sources for vapors present in the area of the tank.

Based on observations made on April 27, 2011, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition, NFPA 99, 1999 Edition, or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

In accordance with NFPA 101 and Section 38.5.1, utilities shall comply with the provisions of Section 9.1. Further, Section 9.1.2 Electric states that electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 of NFPA 70, sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 and interpretations from CMS.

In accordance with Article 370.28(c) of NFPA 70 (1999 Edition) all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Article 250-110.

1. At 8:32 a.m., there was a brown extension cord in use on the floor behind the counter located in the vacated space of a former business (gym).

2. At 9:05 a.m. in the space called the "Community Center", a fractured electrical outlet cover in one corner of that room needed to be replaced.

Surveyor observations were made at the facility on April 26, 2011. The facility failed to ensure the electrical system and its components were always being maintained in accordance with NFPA 70.

Findings include:

In accordance with NFPA 101 and Section 38.5.1, utilities shall comply with the provisions of Section 9.1. Further, Section 9.1.2 Electric states that electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

In accordance with Article 370.28(c) of NFPA 70 (1999 Edition) all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Article 250-110.

In accordance with Article 110-13(a) of NFPA 70 (1999 edition) electrical equipment shall be firmly secured to the surface on which it is mounted.

In accordance with Article 110-26 of the NFPA 70 (1999 Edition) requires that "sufficient access and working space (a minimum clearance of 3 feet) be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment."


1. At 2:34 p.m. in the office of the Sleep Medicine Center, the electrical outlets and wiring were inspected. Above a desktop at the wall, several blue computer wires had not been secured and covered with the appropriate electrical cover plate.


2. At 2:33 p.m.. in the office of the Sleep Medicine Center, the electrical outlets and wiring was inspected. Underneath a desktop a power strip was plugged into an electrical outlet. The power strip was hanging in the air and had not been properly secured to the wall or the desk.

3. At 2:51 p.m. in that part of the building which is not the Sleep Medicine Center, in a conference room two folding tables had been placed against an electrical panel which blocked access to the electrical panel.

Based on observations made on April 26 and 27, 2011, the facility failed to maintain the electrical system and/or its components in accordance with the National Electrical Code, NFPA 70, 1999 Edition.

The findings include:

Unless specifically permitted in Section 400-7, flexible cords (including extension cords) and cables shall not be used as a substitute for the fixed wiring of a structure per Article 400-8 of NFPA 70. Extension cords may be used for temporary wiring in accordance with Articles 305-4(b) and 305-4(c) of NFPA 70.

1. The soiled utility room across from OB room 125 was examined at 3:06 a.m. on April 26, 2011. Two refrigerators were in use in this room. Each refrigerator had an extension cord supplying power to it in lieu of direct connection to the fixed wiring (receptacles) of the building.

Ground Fault Circuit Interrupter (GFCI) receptacles shall be listed in accordance with Articles 110-2 and 110-3 of NFPA 70 and shall have trip times per their listing under UL 498 standards.

2. The GFCI receptacle by the sink in the sub sterile room between operating rooms 1 and 2 was exercised at 7:14 a.m. on April 27, 2011. The receptacle did not break current when the test button was pushed.

3. The GFCI receptacle in the staff break room across from the north surgical recovery beds 1 and 2 was exercised at 7:26 a.m. on April 27, 2011. The receptacle did not break current when the test button was pushed.