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Based on observations, on November 2, 2010 at approximately 2:30 pm onward, the following items were noncompliant, specific findings include:

1. The smoke wall was not complete to the deck above at the cross corridor doors leading to the endoscopy unit

Based on observations, on November 2, 2010 at approximately 2:30 pm onward, the following items were noncompliant, specific findings include:

1. The facility is utilizing special locking systems and is not fully covered by an automatic sprinkler system nor is it fully detected. There is an area in North that does not have as a minimum single station smoke detection in the patient rooms.

Based on observations, on November 2, 2010 at approximately 2:30 pm onward, the following items were noncompliant, specific findings include:

1. The parking lot lighting at the required exit for Pain Center were not verified to be on the emergency circuit (Note: there was only a one bulb fixture at the exit discharge)

2. The Behavioral Health Unit (BHU) required exit from the glass door did not have exit discharge lighting at the exit.

3. The parking lot lighting at the required exit for Physical Therapy and Rehabilitation were not verified to be on the emergency circuit (Note: there was only a one bulb fixture at the exit discharge)

Based on observations, on November 2, 2010 at approximately 2:30 pm onward, the following items were noncompliant, specific findings include:

1. Based on record review and staff interview, the facility sprinkler system was not in accordance with NFPA 25 - Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems (1999 edition). The following items were outstanding from the recent quarterly inspection. Interview with staff indicated that the items were under contract for repair.

A. Hydraulic data plate for the sprinkler riser for the ED and OR addition was missing.

B. The tamper switch at the helipad was not in working condition.

Based on observations, on November 2, 2010 at approximately 2:30 pm onward, the following items were noncompliant, specific findings include:

1. The Behavioral Health Unit dirty utility door opens into the corridor without having a closure installed nor opening 180 degrees to the corridor wall.

Based on observations, on November 2, 2010 at approximately 2:30 pm onward, the following items were noncompliant, specific findings include:

1. There were oxygen cylinders located at the liquid oxygen farm that were not covered from extremes of weather.

Based on observations, on November 2, 2010 at approximately 2:30 pm onward, the following items were noncompliant, specific findings include:

1. While testing of the facilities generator systems, during a visual inspection of the remote alarm annunciator, power transferred and an indicator light came on at the annunciator panel, however this area of the panel was not labeled to indicated what was functioning. (Large generator)

2. While testing of the facilities generator systems, during a visual inspection of the remote alarm annunciator, the annunciator in the Behavioral Health Unit did not indicate that the generator was running. (Smaller generator)

Based on observations, on November 2, 2010 at approximately 2:30 pm onward, the following items were noncompliant, specific findings include:

1. The medical refrigerator was not verified to be on an emergency circuit at the ICU nurse's station
2. The medical refrigerator was not verified to be on an emergency circuit at the North nurse's station

Based on observations, on November 2, 2010 at approximately 2:30 pm onward, the following items were noncompliant, specific findings include:

1. During testing of the facilities fire alarm system which consists of several components the elevator recall smoke detection system was tested. During this test the smoke curtain did not function properly. The smoke curtain closed half way and stopped not sealing this area from smoke.

NOTE: this condition was at the Emergency Department Elevator