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Based on observation the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On November 1, 2011 the surveyors, accompanied by the Environmental Health & Safety, Quality Specialist,and Maintenance Technician, observed that the following corridor have penetrations and do not have a fire resistance rating of not less than 1/2 hour.

1. LHH 5130, conduit opening above corridor door 5013
2. North hallway across from room 5021, approximately 1/2 inch open conduit
3. LHH 5128, penetrations in the corridor wall
4. LHH 3302, caulk pipe chases

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 18. 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18. 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On November 1, 2011 the surveyors, accompanied by the Director of Facilities Services, Environmental Health & Safety, Quality Specialist, Quality Management RN, and Maintenance Technician, observed that the following corridor doors would not tightly close when tested.

1. Fifth floor, CUICU clinical Educator, rated door has holes through the door
2. OR suite door LHH 3427, gap greater than 1/8 inch, no astragal
3. Tri City Cardiology, suite 301, seals torn gap greater than 1/2 inch
4. OR 1, nine holes in doors
5. OR 2, eight holes in doors
6. LHH 3404, door on closure will not positively latch when tested three of three times
7. LHH 3133, torn seal, gap approximately 1/2 inch

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN,

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ? hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On November 1, 2011 the surveyors, accompanied by the Environmental Health & Safety, Quality Specialist, and Maintenance Technician, observed that the following Smoke Barriers have penetrations:

1. LHH 5130, Smoke barrier, to include door will not close tight
2. LHH 5128, Smoke barrier
3. LHH 4800, Smoke barrier by room 4043

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

Based on observation the facility failed to provide a self-closing or an automatic-closing device in a hazardous area.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.1, "Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Findings Include:

On November 1, 2011 the surveyors, accompanied by the Director of Facilities Services, Environmental Health & Safety, Quality Specialist, Quality Management RN, and Maintenance Technician, observed that the following self closing doors would not tightly close when tested.

1. LHH 5073 Soiled Utility would not positively latch when tested three of three times
2. LHH 3419 EVS closet would not positively latch when tested three of three times

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN,

Failing to install self-closing hardware on a smoke/fire resistance door could cause harm to residents in time of a fire.

Based on observation the facility failed to maintain the smoke resistance, of walls, ceilings or pipe chases in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19,. Section 19.3.2.1 Requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls, doors, and ceilings must be able to resist the passage of smoke.

Findings include:

On November 1, 2011 the surveyors, accompanied by the Director of Facilities Services, Environmental Health & Safety, Quality Specialist, Quality Management RN, and Maintenance Technician, observed that the following penetrations:

1. LHH 3302, pipes need calking in the janitorial room

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN.

Failing to fill pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which will cause harm to the patients.

Based on observation the facility failed to keep automatic sprinkler heads free of lint and grease.

NFPA 101, Life Safety Code, 2000 Edition, Chapter 18, Section 18.3.5.1, or Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved supervised automatic sprinkler system in accordance with 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the installation of Sprinkler Systems." NFPA 13, Chapter 12, Section 12-1 "General" "A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25....NFPA 25, Chapter 2, Section 2-2.1 "Sprinklers" 2-2.1.1 ...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).

Findings Include:

On November 1, 2011 the surveyors, accompanied by the Director of Facilities Services, Environmental Health & Safety, Quality Specialist, Quality Management RN, and Maintenance Technician, observed that the following automatic sprinkler heads covered with either lint, grease or paint:

1. Dietary, LHH 4401 two of three sprinklers, lint
2. Lab Room, LHH 4644, one of one sprinkler, lint
3. Rooms 4012, and 4013, lint
4. Supply room, clean utility LHH 4638, sprinklers, lint
5. Soiled utility, LHH 4620, paint
6. Deli office, paint
7. Deli Line, three of three sprinklers, lint

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN


Failure to maintain the sprinkler heads could result in a malfunction during a fire. Sprinkler heads are U.L. listed to respond to a calculated ceiling temperature. Grease and lint on the head could slow that response or disable the sprinkler head. This will cause harm to patients and staff.

Based on observation the facility failed to provide a medical gas cylinder storage room free of combustible materials.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings include:

On November 1, 2011 the surveyors, accompanied by the Environmental Health & Safety, Quality Specialist, and Maintenance Technician, observed that the following E-type oxygen cylinders totaling ten stored in the Second floor Cardiac Rehabilitation storage room next to combustibles and electrical.

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which will cause harm to the patients.

Based on Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On November 1, 2011 the surveyors, accompanied by the Environmental Health & Safety, Quality Specialist, and Maintenance Technician, observed that the following refrigerators, microwave, and coffee pots plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms:

1. Fifth floor, staff Break room, coffee pot
2. Fifth floor, CUPCU Charge Nurse, refrigerator
3. Second floor, CMO office, refrigerator
4. Chief HRO, refrigerator
5. Basement, Quality Directors office, coffee pot

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

Based on observation the facility failed to provide protection from electrical shock.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19-5.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code. NEC, 1999, ARTICLE 110, SECTION 110-12 (a) Unused Openings. "Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment."

On November 1, 2011 the surveyors, accompanied by the Environmental Health & Safety, Quality Specialist, and Maintenance Technician, observed the following:

1. LHH 4401 Smoke barrier, by Case Manager/Social Worker office, was missing a cover to an electrical appliance exposing energized electrical wiring, and a J-box with no cover, exposing energized electrical wiring
2. LHH 4645 Smoke barrier, J-box with no cover, exposing energized electrical wiring
3. LHH 4800 Smoke barrier, J-box with no cover, exposing energized electrical wiring
4. LHH 2405 Electrical room, two J-boxs with no cover, exposing energized electrical wiring

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN

Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patient.

Based on observation the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On November 1, 2011 the surveyors, accompanied by the Environmental Health & Safety, Quality Specialist,and Maintenance Technician, observed that the following corridor have penetrations and do not have a fire resistance rating of not less than 1/2 hour.

1. LHH 5130, conduit opening above corridor door 5013
2. North hallway across from room 5021, approximately 1/2 inch open conduit
3. LHH 5128, penetrations in the corridor wall
4. LHH 3302, caulk pipe chases

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 18. 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18. 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On November 1, 2011 the surveyors, accompanied by the Director of Facilities Services, Environmental Health & Safety, Quality Specialist, Quality Management RN, and Maintenance Technician, observed that the following corridor doors would not tightly close when tested.

1. Fifth floor, CUICU clinical Educator, rated door has holes through the door
2. OR suite door LHH 3427, gap greater than 1/8 inch, no astragal
3. Tri City Cardiology, suite 301, seals torn gap greater than 1/2 inch
4. OR 1, nine holes in doors
5. OR 2, eight holes in doors
6. LHH 3404, door on closure will not positively latch when tested three of three times
7. LHH 3133, torn seal, gap approximately 1/2 inch

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN,

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ? hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On November 1, 2011 the surveyors, accompanied by the Environmental Health & Safety, Quality Specialist, and Maintenance Technician, observed that the following Smoke Barriers have penetrations:

1. LHH 5130, Smoke barrier, to include door will not close tight
2. LHH 5128, Smoke barrier
3. LHH 4800, Smoke barrier by room 4043

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

Based on observation the facility failed to provide a self-closing or an automatic-closing device in a hazardous area.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.1, "Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Findings Include:

On November 1, 2011 the surveyors, accompanied by the Director of Facilities Services, Environmental Health & Safety, Quality Specialist, Quality Management RN, and Maintenance Technician, observed that the following self closing doors would not tightly close when tested.

1. LHH 5073 Soiled Utility would not positively latch when tested three of three times
2. LHH 3419 EVS closet would not positively latch when tested three of three times

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN,

Failing to install self-closing hardware on a smoke/fire resistance door could cause harm to residents in time of a fire.

Based on observation the facility failed to maintain the smoke resistance, of walls, ceilings or pipe chases in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19,. Section 19.3.2.1 Requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls, doors, and ceilings must be able to resist the passage of smoke.

Findings include:

On November 1, 2011 the surveyors, accompanied by the Director of Facilities Services, Environmental Health & Safety, Quality Specialist, Quality Management RN, and Maintenance Technician, observed that the following penetrations:

1. LHH 3302, pipes need calking in the janitorial room

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN.

Failing to fill pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which will cause harm to the patients.

Based on observation the facility failed to keep automatic sprinkler heads free of lint and grease.

NFPA 101, Life Safety Code, 2000 Edition, Chapter 18, Section 18.3.5.1, or Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved supervised automatic sprinkler system in accordance with 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the installation of Sprinkler Systems." NFPA 13, Chapter 12, Section 12-1 "General" "A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25....NFPA 25, Chapter 2, Section 2-2.1 "Sprinklers" 2-2.1.1 ...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).

Findings Include:

On November 1, 2011 the surveyors, accompanied by the Director of Facilities Services, Environmental Health & Safety, Quality Specialist, Quality Management RN, and Maintenance Technician, observed that the following automatic sprinkler heads covered with either lint, grease or paint:

1. Dietary, LHH 4401 two of three sprinklers, lint
2. Lab Room, LHH 4644, one of one sprinkler, lint
3. Rooms 4012, and 4013, lint
4. Supply room, clean utility LHH 4638, sprinklers, lint
5. Soiled utility, LHH 4620, paint
6. Deli office, paint
7. Deli Line, three of three sprinklers, lint

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN


Failure to maintain the sprinkler heads could result in a malfunction during a fire. Sprinkler heads are U.L. listed to respond to a calculated ceiling temperature. Grease and lint on the head could slow that response or disable the sprinkler head. This will cause harm to patients and staff.

Based on observation the facility failed to provide a medical gas cylinder storage room free of combustible materials.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, Section 8-3.1.11 "Storage Requirements" Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic. feet.." (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system..."

Findings include:

On November 1, 2011 the surveyors, accompanied by the Environmental Health & Safety, Quality Specialist, and Maintenance Technician, observed that the following E-type oxygen cylinders totaling ten stored in the Second floor Cardiac Rehabilitation storage room next to combustibles and electrical.

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which will cause harm to the patients.

Based on Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On November 1, 2011 the surveyors, accompanied by the Environmental Health & Safety, Quality Specialist, and Maintenance Technician, observed that the following refrigerators, microwave, and coffee pots plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms:

1. Fifth floor, staff Break room, coffee pot
2. Fifth floor, CUPCU Charge Nurse, refrigerator
3. Second floor, CMO office, refrigerator
4. Chief HRO, refrigerator
5. Basement, Quality Directors office, coffee pot

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

Based on observation the facility failed to provide protection from electrical shock.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19-5.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code. NEC, 1999, ARTICLE 110, SECTION 110-12 (a) Unused Openings. "Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment."

On November 1, 2011 the surveyors, accompanied by the Environmental Health & Safety, Quality Specialist, and Maintenance Technician, observed the following:

1. LHH 4401 Smoke barrier, by Case Manager/Social Worker office, was missing a cover to an electrical appliance exposing energized electrical wiring, and a J-box with no cover, exposing energized electrical wiring
2. LHH 4645 Smoke barrier, J-box with no cover, exposing energized electrical wiring
3. LHH 4800 Smoke barrier, J-box with no cover, exposing energized electrical wiring
4. LHH 2405 Electrical room, two J-boxs with no cover, exposing energized electrical wiring

During the exit conference on November 1, 2011, the above findings were again acknowledged by the Chief Executive Officer, Director of Facilities, Environmental Health & Safety, Two Quality Specialists, Quality Management RN

Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patient.