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Based on observations, record review and confirmed by staff, the hospital failed to assure that the building is of a conforming construction type. Section 19.1.6.2 requires buildings 2-stories in height to be of at least Type I (443), Type I (332) or Type II (222). If the building is fully sprinklered it may be of Type II (111), Type II (000), Type III (211), Type IV (2HH) or Type V (111) construction.

THE FINDINGS INCLUDE:

- While performing the building tour on both 3/11/10 and 3/12/10, it was noted that the building is not protected throughout by the automatic sprinkler system.
The building is of 2-story Type II (000) construction type as listed on the statement of conditions performed by the hospital's independent consultant. This was also verified by LSC staff while conducting the building tour and viewing the actual construction methods. Although there is some sprinkler protection provided in certain areas of the building, none of the smoke compartments are considered to be fully sprinklered. The building is required to be fully sprinklered per the construction classification Type II (000).

This was acknowledged by the Supervisor of Plant Operations during the building tour.

Based on observations and confirmed by staff, the facility failed to assure corridor walls are maintained as required.

THE FINDINGS INCLUDE:

On March 12, 2010, several unsealed corridor wall penetrations were noted, along the C-wing, 2nd floor level, south corridor walls above the in-lay ceiling tiles. These approximately 2" x 2" unsealed penetrations were noted where the roof truss met the corridor wall.

These were also noted by the facility's maintenance staff.

Based on observations and confirmed by staff, the facility failed to assure that corridor doors close and latch properly into the door frames. CMS S&C 07-18 dated April 20, 2007 states "In a smoke compartment that is not equipped with a complete automatic sprinkler system, a gap between the face of a corridor door and the door stop should not exceed 1/4-inch, provided that the door latch mechanism is functioning".

THE FINDINGS INCLUDE:

During the morning and afternoon hours of March 11, 2010, while conducting a building tour for the LSC survey the following items were noted:
1. The corridor doors to patient rooms: #142, #144, #145, #147, #208, #214, and #247 did not latch in their respective door frames.
2. The space between the door face and the door stop exceeded 1/4" at the corridor door to patient room #207 (7/8") and patient room # 204 (5/8").
3. The following first floor level B-wing corridor doors are equipped with kick-type door stops: the south corridor's PA-room, the chart room, and the nurses' sitting room, and the north corridor's PA-room.

These were also noted by the facility's Director of Plant Operations.

Based on observations and confirmed by staff, corridor walls are not constructed as required. Section 19.3.6.2.3 states fixed fire window assemblies in accordance with 8.2.3.2.2 shall be permitted in corridor walls. Section 8.2.3.2.2 states fire window assemblies shall be permitted in fire barriers having a required fire resistance rating of 1 hour or less and shall be of an approved type with the appropriate fire protection rating for the location in which they are installed.

THE FINDINGS INCLUDE:

During the morning hours of 3/11/10 while touring the building, it was noted that plain glass vision panels are used in corridor walls and doors to the Day Room on the 2nd floor A-wing. The corridor walls to the room (approximately 20' x 37') are constructed of plain glass. The smoke compartment in which this room is located is not equipped with a complete automatic sprinkler system.

This was acknowledged by the Supervisor of Plant Operations during the building tour.

Based on observations, the facility failed to assure that proper smoke barrier walls are provided as required. Section 8.3.6.1 requires pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers to be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or to be protected by an approved device that is designed for the specific purpose.

THE FINDINGS INCLUDE:

On the morning of March 12, 2010, the 2nd floor level, C-wing one-hour fire resistive smoke barrier as noted on the drawings dated Rev. January 2009, is not continuous above the ceiling to the roof deck above. An unsealed electrical penetration has penetrated the smoke barrier noted, above the in-lay ceiling tiles at the cross corridor doors.

This was also noted by the facility maintenance staff.

Based on observations and confirmed by staff, the hospital failed to assure that hazardous area's are separated as required.

THE FINDINGS INCLUDE:

- During the building tour on both 3/11/10 and 3/12/10, the following items were found to be deficient regarding hazardous areas:

1) The door to the basement level maintenance shop is equipped with an electrical strike plate which disengages when a button is depressed. However, when the electrical power is disengaged to the door mechanism, the strike plate defaults to the open/unlocked position. As a result, the door is not self latching as required.

2) The non-sprinklered electrical room in the kitchen area is equipped with a non-rated door.

3) The basement level central supply room is equipped with two corridor doors. One of these doors is held open using a bungee cord. The other door has a 3/8" gap between the edge of the door and outside edge of the door stop.

4) The door to the soiled utility room on 1st floor A-wing does not self close & latch. The door is currently hitting the door frame preventing the door from fully closing as required.

5) The basement area electrical room opposite stair #8 has a 10" x 10" transfer grill in the corridor wall. The duct work has been capped with a door but the fire damper is still in the open position.

This was acknowledged by the Supervisor of Plant Operations during the hospital tour.

Based on observations, the facility failed to assure that exits are constructed as required

THE FINDINGS INCLUDE:

The facility failed to assure that stairs are protected by 1-hr fire resistive construction as noted during LSC survey building tour on March 11, 2010, and March 12, 2010.

1. The stair latch mechanisms located on stair #1 (2nd floor level), stair #2 (1st & 2nd floor levels), stair #5 (1st floor level), and stair #6 (1st floor level), are equipped with a latch mechanism that remains in the retracted position when operated so that the door does not automatically re-latch when released from the open position.

2. The Stair #3 door to the Ambulator Care Building, at the 2nd floor level, has two (2) - 1/2" diameter holes through the door where the door locking device was installed and relocated.

3. The Stair #4 door, at the 2nd floor level when opened to the stair is held open by the floor mounted door stop, improperly holding the door in the open position.

4. The stair #6 door, at the 2nd floor level, sags so that when in the closed position the door latch mechanism does not engage in the strike plate.

These were also noted by the facility's Director of Plant Operations.

Based on observations the facility failed to assure that the egress headroom is maintained as required.
Section 7.1.5 requires that headroom in a means of egress be no less than 7'-6" to ceilings and no less than 6'-8" to any projection measured from the floor. Exception #1 allows existing buildings to have a ceiling height of not less than 7'-0" in height. Section 7.3.2 states the width of means of egress shall be measured in the clear at the narrowest point of the exit component under consideration.
The exception to 7.3.2 states projections not more than 3 1/2 inches on each side shall be permitted at 38 inches and below.

THE FINDINGS INCLUDE:

- On the morning of March 12, 2010, it was observed that three 15" x 17" computer monitors are mounted on the exit egress wall in the corridor. The monitors extend seven (7) inches into the corridor and are mounted five (5) feet from the floor. They are located outside of rooms 305, 314, and 322. They are mounted so that when a person walks down the corridor holding onto the hand rail, their heads have the capability of coming into contact with the monitors.
This was confirmed by the Director of Facilities and the Administrator.

Based on observation, the facility failed to assure that illumination in the means of egress be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Section 4.6.12 requires that whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable N.F.P.A. requirements or as directed by the authority having jurisdiction.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of March 11, 2010, while conducting a building tour for the LSC survey the following items were noted:
1. (11:15 AM) The light fixture on the outside of the building at stair #7 can be turned on /off by a light toggle switch, accessible to all persons, located inside the stair. This is the only exterior illumination near the exit discharge.
2. (11:35 AM) One light fixture located on the top level and one light fixture located on the discharge level of stair #2, can be turned on /off by a light toggle switch, accessible to all persons, located inside the stair. This is the only interior illumination within the stair as two (2) additional light fixtures located in the stair have burned out bulbs.
3. (2:25 PM) One light fixture located on the top level and one light fixture located on the discharge level of stair #4, can be turned on /off by a light toggle switch, accessible to all persons, located inside the stair. This is the only interior illumination within the stair as two (2) additional light fixtures located in the stair have burned out bulbs.
4. (3:10 PM) One light fixture located on the top level and one light fixture located on the discharge level of stair #5, can be turned on /off by a light toggle switch, accessible to all persons, located inside the stair. This is the only interior illumination within the stair as two (2) additional light fixtures located in the stair have burned out bulbs.
5. (1:50 PM) The B-wing second floor level south corridor is equipped with two (2) corridor wall mounted light toggle switches, accessible to all persons, that allows all of the ceiling mounted corridor lights to be turned off so that the corridor can be placed in complete darkness.

These were also noted by the facility's Director of Plant Operations.

During the morning hours of March 12, 2010, while continuing to conduct the building tour for the LSC survey the items noted were fixed, as the facility staff had replaced defective lights located in stair #2, #4, #5, and #7.

Based on record review and staff interview, the hospital failed to assure fire drills are conducted as required.

THE FINDINGS INCLUDE:

- During the morning hours of 3/11/10 while reviewing the fire drill records, the dates & times of the drills were noted as follows:

1st Shift (7:00AM-3:00PM): Drills were satisfactory.

2nd Shift (3:00PM-11:00PM): 12/22/09 @ 5:00PM; 11/12/09 @ 3:45PM; 8/18/09 @ 3:45PM; 6/25/09 3:30PM; 5/20/09 @ 3:35PM and 2/9/09 @ 4:00PM.

3rd Shift (11:00PM-7:00AM): 12/9/09 @ 6:45AM; 9/16/09 @ 6:45AM; 6/24/09 @ 6:15AM and 3/11/09 @ 6:30AM.

After reviewing all of the fire drills provided, the following deficiencies were noted:

1) The drill times on the 2nd shift are not varied as the largest fluctuation between times is 75-minutes. The entire 8-hour shift period is not utilized to conduct the actual drills.

2) The drill times on the 3rd shift are not varied as the largest fluctuation between times is 30-minutes. The entire 8-hour shift period is not utilized to conduct the actual drills.

This was acknowledged by the Supervisor of Plant Operations during the record review process.

Based on observations and confirmed by staff, the hospital failed to assure that smoke detectors are installed as required. NFPA 72 section 2-3.5.1 states smoke detectors shall not located in a direct airflow nor closer than three feet (3') from an air supply diffuser or return air opening.

THE FINDING INCLUDE:

- During the building tour on both 3/11/10 and 3/12/10, numerous smoke detectors were noted as being less than three feet (3') from an air diffuser. These include but are not limited to the following basement locations:
1) Employee Health office
2) Administrator assistance room
3) Case Management office
4) The X-ray corridor
5) Blood drawing room

This was acknowledged by the Supervisor of Plant Operations during the building tour.

Based on observation , the facility failed to provide a complete automatic sprinkler protection system to cover all areas of the building. This was confirmed by the maintenance staff.

THE FINDINGS INCLUDE:

Automatic sprinkler protection is not provided throughout the facility as noted on the facility plans revised January 2009. This is also noted as a non-compliant construction type under ID Prefix K12, because the facility is not equipped with a complete automatic sprinkler system.

This was acknowledged by the facility's Director of Plant Operations, who indicated that a plan for improvement includes installation of a complete automatic sprinkler system.

Based on observations, record review, and confirmed by staff, the hospital failed to assure that sprinkler systems are maintained as required. Section 1-8 states records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.
NFPA 25 section 2.3.3 states waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector's test connection which simulates activation of a sprinkler head.
NFPA 13 section 5.3.1.5.2 states when existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.
NFPA 25 section 2.3.2 states gauges on sprinkler systems shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
NFPA 25 section 9.3.5 states the operating stems of outside screw and yoke valves shall be lubricated annually. The valve then shall be completely closed and reopened to test its operation and distribute the lubricant.
Section 5.5.1 states a preventive maintenance program shall be established on all components of the fire pump assembly in accordance with the manufacturer ' s recommendations. Records shall be maintained on all work performed on the pump, driver, controller, and auxiliary equipment.
In the absence of manufacturer ' s recommendations for preventive maintenance, Table 5-5.1 provides alternative requirements.
NFPA 13 section 5-6.3.3 states sprinklers shall be located a minimum of 4 in. (102 mm) from a wall.

THE FINDINGS INCLUDE:

- While conducting the record review process during the morning hours on 3/11/10 and during the building tour on both 3/11/10 and 3/12/10, the following sprinkler system deficiencies were noted:

1) The sprinkler system is not inspected/tested on a quarterly basis as required. The testing documentation provided by the hospital is dated 12/1/09 and 3/5/09. The hospital failed to have the sprinkler system inspected/tested during the 2nd quarter (April, May, June) and 3rd quarter (July, August, September) of 2009. The main sprinkler valves were also checked for verification but sprinkler tags were not provided to substantiate testing dates.

2) The pre-action sprinkler system located in stair #2 has not been tested/inspected since 3/4/08. The documentation provided does not list this system as being present in the building. The tag attached to the valve is dated 3/4/08.

3) The main server room is protected by standard response sprinkler heads and quick response sprinkler heads alike.

4) The sprinkler gauges are dated 1996 and have not been tested according to sprinkler records.

5) The two sprinkler inspection reports which were provided do not document that the OS&Y valves have been lubricated and operated as required.

6) There is no documentation to substantiate that the fire pump is maintained as outlined in table 5-5.1. The weekly slips provided just signify that the pump was operated for 10-minutes without preventative maintenance work being performed. Note: The pump did have an annual inspection on 5/7/09.

7) The basement level maintenance shop has a sprinkler head located 1/2" from the wall of an extending soffit. As a result of the placement of this head, there is a portion of the room which is not protected by the sprinkler system.

This was acknowledged by the Supervisor of Plant Operations during the record review process and building tour.

Based on observations and confirmed by staff, the hospital failed to assure that fire extinguishers are properly provided. NFPA 10 section 2-1 states the selection of fire extinguishers for a given situation shall be determined by the character of the fires anticipated, the construction and occupancy of the individual property, the vehicle or hazard to be protected, ambient-temperature conditions, and other factors. Section 3-2.1 states minimal sizes of fire extinguishers for the listed grades of hazards shall be provided on the basis of Table 3-2.1, except as modified by 3-2.2. Fire extinguishers shall be located so that the maximum travel distances shall not exceed those specified in Table 3-2.1. Table 3-2.1 lists a minimum class 2-A extinguisher be provided with a maximum travel distance of 75 ft. before reaching an extinguisher.

THE FINDINGS INCLUDE:

- While touring the building on the afternoon of 3/12/10, the following deficiencies were noted regarding fire extinguishers:

1) Three of the extinguishers provided in the basement area are only Type B:C and not the required minimum of a Type 2-A.
Note: These were replaced during the survey.

2) The travel distance to reach an extinguisher in the basement area is approximately 90 feet.

This was acknowledged by the Supervisor of Plant Operations during the hospital tour.

Based on observations and confirmed by staff, the hospital failed to assure that utilities comply with the provisions of Section 9-1. Gas equipment shall be installed in accordance with NFPA #54, #90A, and per the manufacturers specifications. NFPA #54, Section 6.4.3 requires that provisions for makeup air be provided with a minimum free area of one square inch for each 1000 Btu per hour total input rating of the dryers installed. NOTE: A 100 square inch louvered opening provides approximately 75 square inches of free area. NFPA #90A, Section 2.3.11.1 prohibits using corridors as a supply air system to adjoining areas.
Section 6.4.5 requires ducts for exhausting clothes dryers shall not be put together with sheet-metal screws or other fastening means which extend into the duct and which can catch lint and reduce the efficiency of the exhaust system.

THE FINDINGS INCLUDE:

- While touring the hospital on the afternoon of 3/12/10, it was noted that the 120,000 Btu gas fired dryer is not installed/maintained as required. The following items were noted:

1) The room housing the dryer is not equipped with any make-up provisions.
2) The exhaust vents are fastened together using sheet-metal screws.

This was acknowledged by the Supervisor of Plant Operations during the hospital tour.

Based on observations and documentation provided, the hospital failed to assure that kitchen hood exhaust systems are properly maintained. NFPA 96 section 8.3.1.2 states when a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

THE FINDINGS INCLUDE:

- The hospital has a total of three exhaust hoods/vents, two in the main kitchen and one in the cafeteria. The paper work provided states the hoods were last cleaned on 10/21/09 by a cleaning vendor. The two (2) main kitchen hoods do not have the required labels indicating the cleaning has occurred. The cafeteria hood does have the sticker attached to the hood.

This was acknowledged by the Supervisor of Plant Operations during the hospital tour.

Based on observations during the building tour, the hospital failed to assure compliance with the restrictions of portable space heating devices. Section 9.7.8 states portable space-heating devices shall be prohibited in all health care occupancies.

THE FINDING INCLUDE:

- During the morning hours of 3/12/10 while touring the building, numerous electric space heaters were found in various office locations. These include but are not limited to the following basement locations:

1) The human resources office (two heaters were found in this location)
2) The respiratory office
3) The quality management office

This was acknowledged by the Supervisor of Plant Operations during the hospital tour.

Based on observations and confirmed by staff, the facility failed to assure that egress corridors are kept clear of all obstructions.

THE FINDINGS INCLUDE:

Throughout the morning and afternoon hours of March 11, 2010, and March 12, 2010, while conducting a building tour for the LSC survey the following items were noted on patient care areas A-wing, first and second floor levels; B-wing, first floor level; and C-wing, first and second floor levels:

1. Several, typically three (3) or four (4), computer on wheels (COWs) were noted to be stored along the corridor walls. It was also noticed that many of these machines were plugged into a corridor wall outlet recharging the electrical batteries. ( Some specific examples include: Four (4) COWs between #216 - #213 on 3/11/2010 at 11:15 AM, 3 COWs between #204 - #202 on 3/11/2010 at 11:30 AM, 4 COWs between #116 - #110 on 3/11/2010 at 11:15 AM, 3 COWs between #145 - #134 on 3/11/2010 at 1:30 PM, 4 COWs between #241 - #238 on 3/12/2010 at 9:45 AM).

2. In addition to the storing COWs on the corridors, the facility also stores scales, Personal Protective Equipment Closets (27" x 20" x 65"), four (4) to seven (7) bags of soiled linen and or trash and electric blood pressure cuffs (charging) in corridors.

3. On the basement level corridor, adjacent to the Social Workers office space, open to the "round" corridor, the facility is storing two (2) recycle barrels, a 64 gallon and a 95 gallon (noted 3/12/2010 at 11:50 AM).

These were also noted by the facility's Director of Plant Operations or Plant Operations staff..

Based on observations the facility failed to assure compliance with NFPA #99, section 4.3.1.2.14 refers to identification of piping and shutoffs. Section 4.3.1.2.14 (b) indicates that shutoff valves shall be identified as to the following:
1. The particular medical gas or vacuum system
2. A caution to not close or open the valve except in an emergency
3. The rooms or areas served.
NFPA #99, Section 4.3.5.4.2 requires shutoff valves described in 4.3.1.2.3, 4.3.1.2.3(m), and 4.3.1.2.3(n) to be labeled to reflect the rooms that are controlled by such valves. Valves shall be labeled in substance as follows: CAUTION: (NAME OF MEDICAL GAS) VALVE DO NOT CLOSE EXCEPT IN EMERGENCY THIS VALVE CONTROLS SUPPLY TO . . . .

THE FINDINGS INCLUDE:

Observations while touring the building on March 11, 2010, and March 12, 2010, revealed that the medical gas shut off valves on the C-wing, 2nd floor level, are not identified as to what rooms they controlled.

This was also noted by the facility's Director of Plant Operations.

Based on observations the facility failed to assure compliance with NFPA 99. Sections 8-3.1.11.2(f) and 4.3.1.1.2(a)11d require ordinary electrical wall fixtures in supply rooms to be installed in fixed locations not less than 5 ft above the floor to avoid physical damage.

THE FINDINGS INCLUDE:

During the afternoon of March 12, 2010 It was observed that the Liquid oxygen storage room is used for storage and transfilling. The following deficiencies were noted:

1. The room is not equipped with dedicated mechanical ventilation.

2. The storage room is constructed of less than a one-hour barrier as the walls do not extend to the deck above, they terminate at the underside of the ceiling, and the enclosure door is constructed with a non-rated wood door with no door closure.

3. The electrical switch is located at 48" from the floor level.

4. No signage on the door indicating that liquid oxygen is being transfilled or stored.

5. Staff interview revealed that they prop open the door when transferring is occurring.

This was confirmed by the Director of Facilities and the Administrator.

Based on record review and confirmed by staff, the hospital failed to assure that the generator is run monthly under a load condition for the required 30-minutes. NFPA 110 section 6-4.1 states level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly. NFPA 99 3-4.4.1.1 states generator sets shall be tested twelve (12) times a year with testing intervals not less than 20 days or exceeding 40 days.
NFPA 110 section 6-4.2 states generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Section 6-4.2.2 states diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
Section 6-4.3 states load tests of generator sets shall include complete cold starts.

THE FINDINGS INCLUDE:

During the morning hours of 3/11/10 while performing the record review process, it was noted that the generator is not maintained as required. It was noted that the generator is not run under a load condition on a monthly basis. During four of the months in which a load test was noted, amperage readings were not documented to substantiate that a load was placed on the generator.
The generator log book which is maintained on a weekly & monthly basis was found to contain the following deficiencies regarding monthly load readings:

1) Monthly load tests are as follows:

3/10- No amperage readings taken.
2/10- No load test noted.
1/10- No amperage readings taken.
12/09- No load test noted.
11/09- No amperage readings taken.
10/09- No load test noted.
8/09- No load test noted.
7/09- No amperage readings taken.
6/09- No load test noted.
3-09- No load test noted.
2-09- No load test noted.

2) It was also stated by staff that the generator is transferred to load each time while it is already running and not from a cold start as required.

This was acknowledged by the Supervisor of Plant Operations during the record review process.

Based on observations the facility failed to assure compliance with NFPA #70 "National Electric Code". Article 110, Table 110-26(a) states working spaces in front of electrical panels shall be a minimum of three (3)'. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in., whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels. Article 305-3 permits temporary wiring to be used during periods of construction, remodeling, maintenance, and repair of buildings, during emergencies, and for a period not to exceed 90 days. Article 400-8 prohibits flexible cords from being use as a substitute for the fixed wiring of a structure. LSC 19-5.1

THE FINDINGS INCLUDE:

During the afternoon of March 11, 2010 (1:30 PM) and the morning of March 12, 2010 (9:15 AM), while conducting a building tour for the LSC survey the following was noted:

1. One (1) approximately seven feet long exercise mat and four (4) approximately 30" diameter exercise balls and similar equipment were stored in front of and against the electrical breaker panels located in the second floor level Physical Therapy Gymnasium closet.

2. Strip type (surge arrestor) extension cords are utilized to supplement power to feeding pumps, Intravenous Pumps, hydrocolator in the patient care area storage/utility rooms located on first and second floor levels of A-wing, B-wing, and C-wing.


These were also noted by the facility's Director of Plant Operations.

Based on observations and confirmed by staff, the hospital failed to assure that wall mounted alcohol based hand sanitizers (ABHR) are installed as required.

THE FINDINGS INCLUDE:

During the tour of the facility on the afternoon of March 11, 2010, three (3) ABHR's were mounted on B-wing corridor walls directly above electrical outlets: inside the Outpatient Gym (south corridor), at the north corridor outside of the Occupational Therapy Office, and inside the Occupational Therapy Office, #227.

These were also noted by the facility's Director of Plant Operations.