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The facility did not ensure that the facilities air conditioning and ventilation equipment was in accordance with NFPA 90A: Standard for the Installation of Air Conditioning and Ventilation Systems as required by the LSC.

On 05/25/10 at 10:00 AM, the surveyor was not provided with documentation by the Assistant Director of Plant Operations that the smoke dampers and mechanical fire dampers that were identified as being deficient on the 2009 fire & smoke damper inspection had been repaired and no definitive time table for the completion of the repairs was available at the time of survey.

The facility did not ensure that solid linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity and Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended as required by the LSC.

On 05/24 & 05/25/10 at 09:30 AM and times throughout the survey, the surveyor along with the Assistant Director of Plant Operations observed that the facility was utilizing mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) throughout the facility and the receptacles were not located in rooms protected as a hazardous area when not attended as required by the referenced LSC.

The facility did not ensure that piped in medical gas systems are in compliance with NFPA 99, "Health Care Facilities" Chapter 4.

On 05/25/10 at 11:00 AM, the surveyor was not provided with documentation by the Assistant Director of Plant Operations that the master medical gas alarm panel identified as being non compliant/deficient on the 10/2009 Praxair med gas inspection report had been replaced and no definitive date of replacement was available at the time of survey.

The facility did not ensure that patient care equipment was being inspected as required in NFPA 99 " Health Care Facilities " .

1. On 05/24/10 and 05/25/10 at 09:30 AM and times throughout the survey, the surveyor along with the Assistant Director of Plant Operations observed the heart monitor/ defibrillators on emergency/crash carts throughout the hospital had expired preventive maintenance stickers (04/10 expiration date).

2. On 05/25/10 at 11:30 AM, documentation was not provided by Hospital Administration that all patient care electrical devices are inspected as required in NFPA 99 "Health Care Facilities " and as part of the facilities preventive medical equipment maintenance program, i.e., no records of bio-medical equipment testing was available from May 2009 to present.