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The facility did not ensure that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the referenced LSC.
On 10/25/11 at 1:05PM, the surveyors were not provided with documentation by the Safety Director and the Director of Engineering to indicate that fire drills were conducted on the first shift in the third and fourth quarters of 2010 and the first and third quarters of 2011.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC.
The surveyor, during a review of documentation provided by the Director of Engineering, observed that the facility failed to conduct an obstruction inspection on the entire fire sprinkler system as required by chapter 10 of NFPA 25.

The facility did not ensure that nonflammable medical gas systems and equipment used for the administration of inhalation therapy and for resuscitative purposes was in compliance with NFPA 50 and NFPA 99.
On 10/24/11 at 1:00 PM the surveyor, accompanied by a Maintenance Department employee, observed that the facility failed to provide crash protection to the exterior bulk oxygen storage tank as required by NFPA 50 section 3-5.6;

The facility did not ensure that patient electrical devices were being inspected at least annually as required in NFPA 99 " Health Care Facility ' s " Section 7-6.2.1.2, and as part of the facility ' s preventive maintenance program.
On 10/24/11 at 10:20 AM and at other times throughout the day the surveyor, accompanied by the Safety Director, observed that patient electric beds throughout the facility were not documented as being tested for electrical safety and the facility failed to provide documentation that all patient care electrical devices are inspected as required in NFPA 99, Section 7-5.1.3, 7-5.2.2.1 and 7-6.2.1.2 and as part of the facility ' s preventive maintenance program; i.e. no documentation provided to indicate preventive maintenance and/or electrical safety checks had been conducted within the last year.

The facility failed to follow its established policies and procedures for fire alarms and or disasters within the facility.
On 10/25/11 at 1: 20 PM the surveyor observed during an actual fire alarm activation within the facility that some staff members were reporting to the area of the fire alarm activation without fire extinguishers, as specified in the facility ' s fire plan and numerous staff members were unsure of their duties during a fire emergency within the facility as specified in the facility ' s fire plan i:e; employees questioning if they should evacuate the facility, employees questioning if this was an actual fire and should they respond appropriately.

The facility did not ensure that electrical receptacle outlets located within patient care areas were being inspected at least annually or documenting patient care area hospital-grade receptacles performance based data as required in NFPA 99 " Health Care Facilities " .
On 10/25/11 at 10:00 AM, the surveyor was not provided with documentation that electrical receptacle outlets in patient areas are inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3 and as part of the facilities preventive maintenance program.

The facility did not ensure that Electrical wiring and equipment is in accordance with NFPA 70, NFPA 101 section 9.1.2, and NFPA 99 " Health Care Facilities " .
On 10/24/11 between 9:45 AM and 11:00 AM, the surveyor accompanied by the Safety Director, during a tour of the Operating Suite, observed that the facility was utilizing electrical power strips at the Operating Suite and Procedure Rooms that were not properly mounted, hospital grade approved for patient care areas (operating room and procedure rooms); i.e., computer grade power strips were noted in Operating Room #4 and Procedure Room #2.