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Based on observation and interview with staff, the facility failed to separate a use areas by walls that resist the passage of smoke, the facility failed to protect an area open to the corridor and not in direct supervision staff with an electrically supervised automatic smoke detection system in accordance with 19.3.4. 19.3.6.1, Exception (c) Findings,

The door to the Family Waiting on the 7th Floor had been removed, the room is open to the corridor and does not have a smoke detector.

Based on observation and interview with staff, the facility failed to provide Exit access that is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1 Findings,

The doors serving as a horizontal exit component at the north end between the IT department and the Pain Clinic were locked and did not have an exit light.

Based on observation and interview with staff, the facility failed to hold fire drills at unexpected times under varying conditions, at least quarterly on each shift. The staff is to be familiar with procedures and is aware that drills are part of established routine. 19.7.1.2 Findings,

The Pain Clinic and Laboratory located in the hospital space failed to participate in routine drills held in the building.

Based on observation, interview with staff and review of the fire alarm records, the facility failed to provide documentation the fire alarm system had been tested, and maintained in accordance with NFPA 70 and NFPA 72. 9.6.1.4 Findings,

The smoke evacuation system for the Operating Rooms, magnetic door access control locks, and the fire and smoke dampers were not noted as having been tested on the annual fire alarm test documentation.

The last annual inspection of the fire alarm system was March 4, 2011, which is over the required 12 month interval required for testing.

Based on observation and interview with staff, the facility failed to provide automatic sprinkler system, that provides complete coverage in all areas and that is installed in accordance with NFPA 13. Findings,

In the Kitchen , the freezers and refrigerators were not protected with automatic fire suppression systems.

Based on observation and interview with staff, the facility failed to provide Medical gas storage and administration areas that are protected in accordance with NFPA 99, 4-3.1.1.2 Standards for Health Care Facilities. Findings,

The installation of electrical receptacles are required to be 5 feet above the finished floor. The receptacles were 3 feet above the floor in the Liquid Fill Bulk Storage located on the south side of the hospital.

Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities. Relative humidity is to be maintained equal to, or greater than 35%. NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 19.3.2.3 Findings,

The humidity on January 13, 2012 was less than 35% in all 19 suites. Facility failed to provide corrective action for this day.

Based on observation and interview with staff, the facility failed to separate the Pain Clinic and the Lab from the Hospital by a two hour wall in accordance with NFPA 101 19.1.2.2. Findings,

The pain and lab areas are not part of the hospital and are to be separated by construction of not less than 2-hour construction.

Based on observation and interview with staff, the facility failed to maintain Electrical equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2. Findings,

The Line Isolation Monitors located in the Operating Rooms had not be tested in accordance with NFPA 99, 1999 Edition, Chapter 3-3.3.4.2. LIM shall be tested every 6 months or if self monitoring shall be documented every 12 months. The visual and audible alarms shall be documented - no documentation was available.

Bio Med equipment, CPM Knee Monitor Machine was last tested October 18, 2010 and was not pulled out of service.

Based on observation and interview with staff, the facility failed to separate a use areas by walls that resist the passage of smoke, the facility failed to protect an area open to the corridor and not in direct supervision staff with an electrically supervised automatic smoke detection system in accordance with 19.3.4. 19.3.6.1, Exception (c) Findings,

The door to the Family Waiting on the 7th Floor had been removed, the room is open to the corridor and does not have a smoke detector.

Based on observation and interview with staff, the facility failed to provide Exit access that is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1 Findings,

The doors serving as a horizontal exit component at the north end between the IT department and the Pain Clinic were locked and did not have an exit light.

Based on observation and interview with staff, the facility failed to hold fire drills at unexpected times under varying conditions, at least quarterly on each shift. The staff is to be familiar with procedures and is aware that drills are part of established routine. 19.7.1.2 Findings,

The Pain Clinic and Laboratory located in the hospital space failed to participate in routine drills held in the building.

Based on observation, interview with staff and review of the fire alarm records, the facility failed to provide documentation the fire alarm system had been tested, and maintained in accordance with NFPA 70 and NFPA 72. 9.6.1.4 Findings,

The smoke evacuation system for the Operating Rooms, magnetic door access control locks, and the fire and smoke dampers were not noted as having been tested on the annual fire alarm test documentation.

The last annual inspection of the fire alarm system was March 4, 2011, which is over the required 12 month interval required for testing.

Based on observation and interview with staff, the facility failed to provide automatic sprinkler system, that provides complete coverage in all areas and that is installed in accordance with NFPA 13. Findings,

In the Kitchen , the freezers and refrigerators were not protected with automatic fire suppression systems.

Based on observation and interview with staff, the facility failed to provide Medical gas storage and administration areas that are protected in accordance with NFPA 99, 4-3.1.1.2 Standards for Health Care Facilities. Findings,

The installation of electrical receptacles are required to be 5 feet above the finished floor. The receptacles were 3 feet above the floor in the Liquid Fill Bulk Storage located on the south side of the hospital.

Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99, Standard for Health Care Facilities. Relative humidity is to be maintained equal to, or greater than 35%. NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 19.3.2.3 Findings,

The humidity on January 13, 2012 was less than 35% in all 19 suites. Facility failed to provide corrective action for this day.

Based on observation and interview with staff, the facility failed to separate the Pain Clinic and the Lab from the Hospital by a two hour wall in accordance with NFPA 101 19.1.2.2. Findings,

The pain and lab areas are not part of the hospital and are to be separated by construction of not less than 2-hour construction.

Based on observation and interview with staff, the facility failed to maintain Electrical equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2. Findings,

The Line Isolation Monitors located in the Operating Rooms had not be tested in accordance with NFPA 99, 1999 Edition, Chapter 3-3.3.4.2. LIM shall be tested every 6 months or if self monitoring shall be documented every 12 months. The visual and audible alarms shall be documented - no documentation was available.

Bio Med equipment, CPM Knee Monitor Machine was last tested October 18, 2010 and was not pulled out of service.