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Based on observations and interview it was determined that the facility failed to maintain a Suite in the manner in which it was approved. This resulted in the potential for the spread of fire/smoke within the Suite. Findings include:

1. On January 10, 2011 at 2:26 p.m., room 233 within the ICU sleeping suite was being used as a breakroom, with microwave, coffee pot, and other cooking appliances. Ref. NFPA 101 LSC Sections 18/19.2.3.3 & 18/193.6.

2. On January 11, 2011 at 2:00 p.m., the following remodeling projects were completed without benefit of permits or approval from the Office of State Fire Marshal Healthcare Unit: a) conference rooms created at West end of 3rd floor; b) carpet replaced on 2nd floor; c) PFS - remodeled 4th floor for office space; c) remodeled basement print shop to become the IT department; d) enlarged the Nuclear Medicine room for new equipment on the 1st floor; e) created new office and office area at entrance to Material Management in the basement; f) added storage room to Bio-med from East of their office in the basement; g) added door between centralized scheduling and scheduling in the basement; h) PT remodel - converted office space to be new rehab gym on 1st floor; i) enlarged Mammagraphy room for new equipment on the 1st floor.

Based on observations and interviews it was determined that the facility failed to maintain integrity of fire rated separations. This resulted in the potential for fire/smoke to spread to other areas of the facility, causing the exposure of residents & staff to hazardous products of fire (heat, smoke, toxic gases). Findings include:

1. On January 10, 2011 at 1:50 p.m., there were unsealed ceiling penetrations in the Hospitalist office on the 2nd floor.

2. On January 10, 2011 at 11:55 a.m., the 3rd floor conference rooms project was not reviewed or approved by the Office of State Fire Marshal.

3. On January 10, 2011 at 2:36 p.m., there was a penetration in Suite separation wall from the corridor above entrance to room #224.

4. On January 11, 2011 at 9:15 a.m., there was an unsealed penetration in the sign room RB024.

5. On January 11, 2011 at 2:17 p.m., there was a vent located within 10 feet of the window to room 217.

Based on observations, record review and interviews it was determined that the facility failed to maintain exit corridor doors in accordance with NFPA 80. This resulted in the potential for passage of fire/smoke into the means of egress in the event of a hostile fire event. Findings include:

1. On January 10, 2011 at 11:27 a.m., door #RP001 on the 4th floor did not have a rating tag.

2. On January 10, 2011 at 2:32 p.m., the corridor door to Suite at room #224 was not self or automatic closing.

3. On January 10, 2011 at 2:49 p.m., the door to storage by room #243 did not close and latch.

4. On January 10, 2011 at 3:24 p.m., the smoke doors at elevator 1R at the entrance from OR did not close and latch.

5. On January 10, 2011 at 4:02 p.m., the doors at the West end entrance to the Emergency Dept and OR did not latch.

6. On January 10, 2011 at 4:05 p.m., the corridor doors to the cafeteria did not close and latch and were delaminating. The smoke partition between the dietary and the corridor was also a 45 minute opening protection for the kitchen.

7. On January 10, 2011 at 4:32 p.m., the fire exit door at the nurse's station in ED was blocked with charts.

8. On January 10, 2011 at 4:52 p.m., the cross-corridor door R1066 did not latch when released.

9. On January 11, 2011 at 8:36 a.m., RP002 server room door was blocked from opening 90 degrees.

10. On January 11, 2011 at 8:39 a.m., the storeroom door in the basement was blocked open with a wedge.

11. On January 11, 2011 at 9:30 a.m., facility was not documenting testing and maintenance of smoke and fire doors in accordance with NFPA 80.

Based on observations and interview it was determined that the facility failed to install vision panels in exit corridor and/or cross-corridor doors. This resulted in the potential for injury to residents and staff during emergency conditions. Findings include:

1. On January 10, 2011 at 2:25 p.m., cross-corridor doors R2007 did not have vision panels.

Based on observations and interview it was determined that the facility failed to install/maintain exit access throughout the means of egress. This resulted in the potential for panic and injury during emergency evacuations and relocation. Findings include:

1. On January 10, 2011 at 1:22 p.m., there was a dead-end corridor exceeding 20 feet from stairwell to room #329. Cross-corridor doors open against egress.

2. On January 10, 2011 at 3:10 p.m., there was a dead-end corridor exceeding 20 feet by room #227.

3. On January 10, 2011 at 4:24 p.m., there was a candy machine and a garbage can behind the exit door.

4. On January 10, 2011 at 5:14 p.m., exit door in the B stairwell to the outside lacked a sign stating, "not an exit".

Based on observations and interview it was determined that the facility failed to provide adequate emergency exit illumination to the public way. This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions. Findings include:

1. On January 10, 2011 at 5:16 p.m., there was a single bulb light fixture outside the fire exit from Physical Therapy. Ref. LSC 101, Section 7.8.1.4 & A.7.8.1.4.

Based on observations and interview it was determined that the facility failed to provide adequate emergency exit illumination to the public way. This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions. Findings include:

1. On January 10, 2011 at 5:15 p.m., exterior lighting from stair B did not illuminate 50 feet or to a public way.

2. On January 10, 2011 at 5:20 p.m., there was no exit egress lighting at stair H ground level.

Based on observations, interview and record review it was determined that the facility failed to properly identify exits. This resulted in the potential for panic and confusion during an evacuation. Findings include:

1. On January 10, 2011 at 11:35 a.m., there was an exit sign from the 4th floor office that went to the roof.

Based on observations, record review and interviews it was determined that the facility failed to maintain emergency preparedness plan current and readily available. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 18.7.1.1) Findings include:

1. On January 11, 2011 at 9:30 a.m., the facility's emergency preparedness/disaster plan was outdated, incomplete, inaccurate information, had excessive policy language, and unusable in an emergency. Following are examples: a) the 2nd floor Med Surg nurse's station was unable to find the emergency preparedness manual. Once they did find the manual it was dated 1987; b) the fire plan in the manual did not give instructions, but indicated to go to another plan; c) the "defend in place" policy indicated that patients were safe in their rooms other than the room of the fire; d) manual stated to place a pillow or trash can in front of the patient room door to mark either that the room had been evacuated or the patient was safe in their room; e) review of departmental safety policies indicated last conducted in 1994 (Quality Resources) and 2008 (Med Surg 2nd floor); f) the tabs were not in order of the Table of Contents; g) staff telephone directory (5/1/10) and the hospital phone list (11/2008) were outdated; h) safety management policies were last revised 11/08 and the fire plan was last revised 4/09 (Med Surg) i) none of the manuals throughout the facility matched; j) the smoking policy did not give an explanation, but indicated to go to another plan, & there was no emergency plan for the Helipad.

Based on record review and interview it was determined that the facility failed to provide approved in-service for all staff. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSF 18.7.2.1, A.18.7.1.2, OFC 405.4). Findings include:

1. On January 11, 2011 at 9:30 a.m., the Healthstream for training that was created by the Safety Committee and the newsletter blurbs were not adequate to cover staff competency training listed in Chapter 6 of the Fire & Life Safety Practices manual. There was no table of contents, no earthquake plan, no bomb threat plan, does not address relocation from smoke compartment.

Based on observations, record review and interviews it was determined that the facility failed to maintain fire alarm in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies. Findings include:

1. On January 10, 2011 at 3:01 p.m., fire alarm wiring was improperly terminated at R2056.

Based on observations and interview it was determined that the facility failed to provide smoke detection in accordance with required standards. This potentially leaves patients and staff with no warning to leave in an emergency condition. Findings include:

1. On January 11, 2011 at 8:04 a.m., there was a smoke detector missing in the 2nd floor sleeping room.

Based on observations and interview it was determined that the facility failed to ensure that there was complete sprinkler coverage for all portions of the building. This resulted in the potential for sprinkler failure and for uncontrolled fire progression in the event of a fire. Findings include:

1. On January 10, 2011 at 11:15 a.m., the sprinkler head above air handler #2 in the roof top mechanical room was capped off.

2. On January 10, 2011 at 1:54 p.m., the Communications room R2028 in the 2nd floor stairwell lacked sprinkler protection.

3. On January 10, 2011 at 1:56 p.m., there was a painted sprinkler head in the laundry chute room.

4. On January 10, 2011 at 3:03 p.m., the floor valve room by #226 in the H stairwell was not sprinklered.

5. On January 10, 2011 at 4:55 p.m., there was a missing sprinkler head in the storage area of Cardiopulminary.

6. On January 10, 2011 at 5:18 p.m., the sprinkler closet in stairwell H on the first floor lacked sprinkler protection.

7. On January 11, 2011 at 9:14 a.m., the alcove by the sign room RB024 lack sprinkler protection.

Based on observations, record review and interviews it was determined that the facility failed to ensure that sprinkler system is continuously maintained & in reliable operating condition. This resulted in the potential for system failure during fire emergencies. Findings include:

1. On January 10, 2011 at 1:43 p.m., there was a painted sprinkler head in the closet of R3043, in B stairwell, and inside IT room 2-032.

2. On January 10, 2011 at 1:47 p.m., a light fixture was blocking the sprinkler in Xray reading room on the 3rd floor.

3. On January 10, 2011 at 2:23 p.m., there was a dirty sprinkler head at the Med Surg charting computer station, in exam room #8, clean linen #1029, in R1006 in Lab, in Ultra Sound 1, Outpatient Services waiting area, and in treatment A, bed 2.

4. On January 10, 2011 at 4:09 p.m., there was a corroded sprinkler heads in the kitchen.

5. On January 10, 2011 at 4:12 p.m., the pull station for Ansel system was located higher than 42" to 48" from floor to handle.

6. On January 11, 2011 at 5:27 a.m., the spare sprinkler head box did not have standard sprinkler heads.

7. On January 11, 2011 at 5:15 a.m., the automatic sprinkler gauge on the main riser was dated 1976.

8. On January 11, 2011 at 9:40 a.m., trash containers (dumpsters) were within 5 feet of the building outside of receiving.

Based on observations and interview it was determined that the facility failed to maintain/provide fire extinguishers. This resulted in the potential for fires to progress beyond incipient stage. Findings include:

1. On January 10, 2011 at 1:42 p.m., fire extinguisher cabinets protruded into the corridor width more than 4 inches.

2. On January 11, 2011 at 8:00 a.m., there was no fire extinguisher at the Helipad (4-A:80B). Ref. NFPA 418 Section 9.2

Based on observations and interview it was determined that the facility failed to ensure safe smoking practices. This resulted in the potential for exposing patients to a fire and/or smoke environment. Findings include:

1. On January 11, 2011 at 8:00 a.m., there was an ashtray at the main entrance that was within 10 feet of the front door.

Based on observations, record review and interviews it was determined that the facility failed to properly install building service equipment. This resulted in the potential for a gas leak, unexpected fire, or damage during a seismic event. Findings include:

1. On January 11, 2011 at 7:45 a.m., there was no seismic bracing on the FDC pipe in the laundry store room.

Based on observations and interview it was determined that the facility failed to prohibit the use of portable space heating devices. This resulted in the potential for ignition of nearby combustibles. Findings include:

1. On January 11, 2011 at 8:03 a.m., there was a space heater in exam room A-2.

2. On January 11, 2011 at 8:06 a.m., there was a space heater without tip-over shutoff protection on the 2nd floor at reception.

Based on observations, record review and interviews it was determined that the facility failed to ensure that exit egress remained clear & unobstructed. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency. Findings include:

1. On January 10, 2011 at 2:13 p.m., the phone by room #214 protruded into the corridor more than 4 inches.

2. On January 10, 2011 at 5:05 p.m., there was a newspaper stand in the main lobby entrance obstructing the egress.

Based upon observations and interviews it was determined that the facility failed to ensure that no furnishings or decorations of highly flammable character are used. This resulted in the potential for excessive fire spread. Findings include:

1. On January 10, 2011 at 1:45 p.m., there was a spray foam based tree open to the corridor in the waiting area by room #324.

2. On January 10, 2011 at 2:10 p.m., there was a linen cart being stored in the corridor outside the Intensive Care Unit.

3. On January 10, 2011 at 3:24 p.m., there was a wooden bench at the 1st floor stairwell J.

Based on observations, record review and interviews it was determined that the facility failed to provide safe storage for compressed gas. This resulted in the potential for oxygen tanks to tip over, possibly resulting in an unintentional discharge of compressed gas.. Findings include:

1. On January 10, 2011 at 2:07 p.m., there was an unsecured oxygen cylinder in the corridor by the Med Surg nurse's station.

Based on observations, record review and interviews it was determined that the facility failed to properly maintain the generator. This resulted in the potential for the lack of emergency electrical power. Findings include:

1. On January 11, 2011 at 5:00 a.m., all three generators were not vented 12 feet above grade.

2. On January 11, 2011 at 5:02 a.m., there were no battery powered lights at the generators.

3. On January 11, 2011 at 2:00 p.m., the facility added a 600 KW standby generator without benefit of permits or approval from the Office of State Fire Marshal Healthcare Unit.

Based on observations and interview it was determined that the facility failed to maintain the integrity of the electrical system. This resulted in the potential for injury to patients and staff. Findings include:

1. On January 11, 2011 at 8:05 a.m., The was a missing cover on the junction box in the 2nd floor sleeping room.

Based on observations, record review and interviews it was determined that the facility failed to ensure that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to residents & staff. Findings include:

1. On January 10, 2011 at 12:00 p.m., all three outlets (2p3b41) in treatment room #318 by sinks were not marked as protected by GFCI.

2. On January 10, 2010 at 1:20 p.m., there were outlets within 6' of the sinks in the Cascade Clinic reception bathroom, the OR Decon room, at the sink in Pre-op, in Scope room,and the waiting area across from room #324 that were not protected by GFCI.

3. On January 10, 2011 at 1:25 p.m., there was a relocatable power tap in room #329, at the Accounting printer, at the Administrator Assistants desk, in storage room 212, at the ICU nurse's station, in room 224 on computer cart, attached to TVs in rooms 241 and 242, on the nursery radio, on the computer on wheels in the nursery, in room #243, at nurse's station in Labor & Delivery, at nourishment station by cross corridor door R2058, in Recovery, at the nurse's station in ED, in the Lab, in Ultra Sound 1 & 2, in Mammography, in Nuclear Med, in R1001B, in the gift shop, main lobby, reception desk at the main entrance, to computers in Therapy, in massage therapy, in the Dialysis office, in pre-registration, in IT Director's office, and in the Vice President's office. Interview with Director of Plant Services indicated there are relocatable power taps throughout the facility.

4. On January 10, 2011 at 2:07 p.m., there was a non-patient care relocatable power tap in the Med-Surg corridor charging a med cart.

5. On January 10, 2011 at 2:11 p.m., there were computers on wheels with non-patient care relocatable power taps by Intensive Care Unit.

6. On January 10, 2011 at 2:24 p.m., there was a surge protector plugged into a relocatable power tap in Med Surg doctor's charting station.

7. On January 10, 2011 at 2:53 p.m., there was a toaster, microwave, and coffee maker in the clean utility room inside the Labor & Delivery Suite.

8. On January 10, 2011 at 3:12 p.m., the refrigerator in the Med Surg breakroom was plugged into a relocatable power tap.

9. On January 10, 2010 at 3:34 p.m., there was an extension cord being used in OR1 and OR3. There was a relocatable power tap at the computer in OR1 and OR2 and OR3.

10. On January 10, 2011 at 3:38 p.m., there was a relocatable power tap in the handwash area of the OR charging batteries.

11. On January 10, 2011 at 3:45 p.m., there was a relocatable power tap on a computer at the entrance to Recovery.

12. On January 10, 2011 at 4:17 p.m., there was a surge protector plugged into another surge protector on pop machines by the ED waiting room.

13. On January 10, 2011 at 4:53 p.m., there was a microwave and coffee maker plugged into a relocatable power tap in Radiology Tech area.

14. On January 11, 2011 at 8:02 a.m., there was an extension cord to the small dryer in the laundry room that went out the window.

15. On January 11, 2011 at 8:46 a.m., the electrical panel in Dialysis was blocked by storage.

16. On January 11, 2011 at 8:48 a.m., the cord was not inside cord restraints in the water treatment room for Dialysis.

Based on observations and interviews it was determined that the facility failed to install alcohol gel hand sanitizing dispensing stations away from sources of ignition. This resulted in the potential for injury to residents and staff. Findings include:

1. On January 10, 2011 at 3:36 p.m., there was an alcohol gel hand sanitizing dispenser installed above the light switch in OR2.

Based on observations and interview it was determined that the facility failed to maintain a Suite in the manner in which it was approved. This resulted in the potential for the spread of fire/smoke within the Suite. Findings include:

1. On January 10, 2011 at 2:26 p.m., room 233 within the ICU sleeping suite was being used as a breakroom, with microwave, coffee pot, and other cooking appliances. Ref. NFPA 101 LSC Sections 18/19.2.3.3 & 18/193.6.

2. On January 11, 2011 at 2:00 p.m., the following remodeling projects were completed without benefit of permits or approval from the Office of State Fire Marshal Healthcare Unit: a) conference rooms created at West end of 3rd floor; b) carpet replaced on 2nd floor; c) PFS - remodeled 4th floor for office space; c) remodeled basement print shop to become the IT department; d) enlarged the Nuclear Medicine room for new equipment on the 1st floor; e) created new office and office area at entrance to Material Management in the basement; f) added storage room to Bio-med from East of their office in the basement; g) added door between centralized scheduling and scheduling in the basement; h) PT remodel - converted office space to be new rehab gym on 1st floor; i) enlarged Mammagraphy room for new equipment on the 1st floor.

Based on observations and interviews it was determined that the facility failed to maintain integrity of fire rated separations. This resulted in the potential for fire/smoke to spread to other areas of the facility, causing the exposure of residents & staff to hazardous products of fire (heat, smoke, toxic gases). Findings include:

1. On January 10, 2011 at 1:50 p.m., there were unsealed ceiling penetrations in the Hospitalist office on the 2nd floor.

2. On January 10, 2011 at 11:55 a.m., the 3rd floor conference rooms project was not reviewed or approved by the Office of State Fire Marshal.

3. On January 10, 2011 at 2:36 p.m., there was a penetration in Suite separation wall from the corridor above entrance to room #224.

4. On January 11, 2011 at 9:15 a.m., there was an unsealed penetration in the sign room RB024.

5. On January 11, 2011 at 2:17 p.m., there was a vent located within 10 feet of the window to room 217.

Based on observations, record review and interviews it was determined that the facility failed to maintain exit corridor doors in accordance with NFPA 80. This resulted in the potential for passage of fire/smoke into the means of egress in the event of a hostile fire event. Findings include:

1. On January 10, 2011 at 11:27 a.m., door #RP001 on the 4th floor did not have a rating tag.

2. On January 10, 2011 at 2:32 p.m., the corridor door to Suite at room #224 was not self or automatic closing.

3. On January 10, 2011 at 2:49 p.m., the door to storage by room #243 did not close and latch.

4. On January 10, 2011 at 3:24 p.m., the smoke doors at elevator 1R at the entrance from OR did not close and latch.

5. On January 10, 2011 at 4:02 p.m., the doors at the West end entrance to the Emergency Dept and OR did not latch.

6. On January 10, 2011 at 4:05 p.m., the corridor doors to the cafeteria did not close and latch and were delaminating. The smoke partition between the dietary and the corridor was also a 45 minute opening protection for the kitchen.

7. On January 10, 2011 at 4:32 p.m., the fire exit door at the nurse's station in ED was blocked with charts.

8. On January 10, 2011 at 4:52 p.m., the cross-corridor door R1066 did not latch when released.

9. On January 11, 2011 at 8:36 a.m., RP002 server room door was blocked from opening 90 degrees.

10. On January 11, 2011 at 8:39 a.m., the storeroom door in the basement was blocked open with a wedge.

11. On January 11, 2011 at 9:30 a.m., facility was not documenting testing and maintenance of smoke and fire doors in accordance with NFPA 80.

Based on observations and interview it was determined that the facility failed to install vision panels in exit corridor and/or cross-corridor doors. This resulted in the potential for injury to residents and staff during emergency conditions. Findings include:

1. On January 10, 2011 at 2:25 p.m., cross-corridor doors R2007 did not have vision panels.

Based on observations and interview it was determined that the facility failed to install/maintain exit access throughout the means of egress. This resulted in the potential for panic and injury during emergency evacuations and relocation. Findings include:

1. On January 10, 2011 at 1:22 p.m., there was a dead-end corridor exceeding 20 feet from stairwell to room #329. Cross-corridor doors open against egress.

2. On January 10, 2011 at 3:10 p.m., there was a dead-end corridor exceeding 20 feet by room #227.

3. On January 10, 2011 at 4:24 p.m., there was a candy machine and a garbage can behind the exit door.

4. On January 10, 2011 at 5:14 p.m., exit door in the B stairwell to the outside lacked a sign stating, "not an exit".

Based on observations and interview it was determined that the facility failed to provide adequate emergency exit illumination to the public way. This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions. Findings include:

1. On January 10, 2011 at 5:16 p.m., there was a single bulb light fixture outside the fire exit from Physical Therapy. Ref. LSC 101, Section 7.8.1.4 & A.7.8.1.4.

Based on observations and interview it was determined that the facility failed to provide adequate emergency exit illumination to the public way. This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions. Findings include:

1. On January 10, 2011 at 5:15 p.m., exterior lighting from stair B did not illuminate 50 feet or to a public way.

2. On January 10, 2011 at 5:20 p.m., there was no exit egress lighting at stair H ground level.

Based on observations, interview and record review it was determined that the facility failed to properly identify exits. This resulted in the potential for panic and confusion during an evacuation. Findings include:

1. On January 10, 2011 at 11:35 a.m., there was an exit sign from the 4th floor office that went to the roof.

Based on observations, record review and interviews it was determined that the facility failed to maintain emergency preparedness plan current and readily available. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 18.7.1.1) Findings include:

1. On January 11, 2011 at 9:30 a.m., the facility's emergency preparedness/disaster plan was outdated, incomplete, inaccurate information, had excessive policy language, and unusable in an emergency. Following are examples: a) the 2nd floor Med Surg nurse's station was unable to find the emergency preparedness manual. Once they did find the manual it was dated 1987; b) the fire plan in the manual did not give instructions, but indicated to go to another plan; c) the "defend in place" policy indicated that patients were safe in their rooms other than the room of the fire; d) manual stated to place a pillow or trash can in front of the patient room door to mark either that the room had been evacuated or the patient was safe in their room; e) review of departmental safety policies indicated last conducted in 1994 (Quality Resources) and 2008 (Med Surg 2nd floor); f) the tabs were not in order of the Table of Contents; g) staff telephone directory (5/1/10) and the hospital phone list (11/2008) were outdated; h) safety management policies were last revised 11/08 and the fire plan was last revised 4/09 (Med Surg) i) none of the manuals throughout the facility matched; j) the smoking policy did not give an explanation, but indicated to go to another plan, & there was no emergency plan for the Helipad.

Based on record review and interview it was determined that the facility failed to provide approved in-service for all staff. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSF 18.7.2.1, A.18.7.1.2, OFC 405.4). Findings include:

1. On January 11, 2011 at 9:30 a.m., the Healthstream for training that was created by the Safety Committee and the newsletter blurbs were not adequate to cover staff competency training listed in Chapter 6 of the Fire & Life Safety Practices manual. There was no table of contents, no earthquake plan, no bomb threat plan, does not address relocation from smoke compartment.

Based on observations, record review and interviews it was determined that the facility failed to maintain fire alarm in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies. Findings include:

1. On January 10, 2011 at 3:01 p.m., fire alarm wiring was improperly terminated at R2056.

Based on observations and interview it was determined that the facility failed to provide smoke detection in accordance with required standards. This potentially leaves patients and staff with no warning to leave in an emergency condition. Findings include:

1. On January 11, 2011 at 8:04 a.m., there was a smoke detector missing in the 2nd floor sleeping room.

Based on observations and interview it was determined that the facility failed to ensure that there was complete sprinkler coverage for all portions of the building. This resulted in the potential for sprinkler failure and for uncontrolled fire progression in the event of a fire. Findings include:

1. On January 10, 2011 at 11:15 a.m., the sprinkler head above air handler #2 in the roof top mechanical room was capped off.

2. On January 10, 2011 at 1:54 p.m., the Communications room R2028 in the 2nd floor stairwell lacked sprinkler protection.

3. On January 10, 2011 at 1:56 p.m., there was a painted sprinkler head in the laundry chute room.

4. On January 10, 2011 at 3:03 p.m., the floor valve room by #226 in the H stairwell was not sprinklered.

5. On January 10, 2011 at 4:55 p.m., there was a missing sprinkler head in the storage area of Cardiopulminary.

6. On January 10, 2011 at 5:18 p.m., the sprinkler closet in stairwell H on the first floor lacked sprinkler protection.

7. On January 11, 2011 at 9:14 a.m., the alcove by the sign room RB024 lack sprinkler protection.

Based on observations, record review and interviews it was determined that the facility failed to ensure that sprinkler system is continuously maintained & in reliable operating condition. This resulted in the potential for system failure during fire emergencies. Findings include:

1. On January 10, 2011 at 1:43 p.m., there was a painted sprinkler head in the closet of R3043, in B stairwell, and inside IT room 2-032.

2. On January 10, 2011 at 1:47 p.m., a light fixture was blocking the sprinkler in Xray reading room on the 3rd floor.

3. On January 10, 2011 at 2:23 p.m., there was a dirty sprinkler head at the Med Surg charting computer station, in exam room #8, clean linen #1029, in R1006 in Lab, in Ultra Sound 1, Outpatient Services waiting area, and in treatment A, bed 2.

4. On January 10, 2011 at 4:09 p.m., there was a corroded sprinkler heads in the kitchen.

5. On January 10, 2011 at 4:12 p.m., the pull station for Ansel system was located higher than 42" to 48" from floor to handle.

6. On January 11, 2011 at 5:27 a.m., the spare sprinkler head box did not have standard sprinkler heads.

7. On January 11, 2011 at 5:15 a.m., the automatic sprinkler gauge on the main riser was dated 1976.

8. On January 11, 2011 at 9:40 a.m., trash containers (dumpsters) were within 5 feet of the building outside of receiving.

Based on observations and interview it was determined that the facility failed to maintain/provide fire extinguishers. This resulted in the potential for fires to progress beyond incipient stage. Findings include:

1. On January 10, 2011 at 1:42 p.m., fire extinguisher cabinets protruded into the corridor width more than 4 inches.

2. On January 11, 2011 at 8:00 a.m., there was no fire extinguisher at the Helipad (4-A:80B). Ref. NFPA 418 Section 9.2

Based on observations and interview it was determined that the facility failed to ensure safe smoking practices. This resulted in the potential for exposing patients to a fire and/or smoke environment. Findings include:

1. On January 11, 2011 at 8:00 a.m., there was an ashtray at the main entrance that was within 10 feet of the front door.

Based on observations, record review and interviews it was determined that the facility failed to properly install building service equipment. This resulted in the potential for a gas leak, unexpected fire, or damage during a seismic event. Findings include:

1. On January 11, 2011 at 7:45 a.m., there was no seismic bracing on the FDC pipe in the laundry store room.

Based on observations and interview it was determined that the facility failed to prohibit the use of portable space heating devices. This resulted in the potential for ignition of nearby combustibles. Findings include:

1. On January 11, 2011 at 8:03 a.m., there was a space heater in exam room A-2.

2. On January 11, 2011 at 8:06 a.m., there was a space heater without tip-over shutoff protection on the 2nd floor at reception.

Based on observations, record review and interviews it was determined that the facility failed to ensure that exit egress remained clear & unobstructed. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency. Findings include:

1. On January 10, 2011 at 2:13 p.m., the phone by room #214 protruded into the corridor more than 4 inches.

2. On January 10, 2011 at 5:05 p.m., there was a newspaper stand in the main lobby entrance obstructing the egress.

Based upon observations and interviews it was determined that the facility failed to ensure that no furnishings or decorations of highly flammable character are used. This resulted in the potential for excessive fire spread. Findings include:

1. On January 10, 2011 at 1:45 p.m., there was a spray foam based tree open to the corridor in the waiting area by room #324.

2. On January 10, 2011 at 2:10 p.m., there was a linen cart being stored in the corridor outside the Intensive Care Unit.

3. On January 10, 2011 at 3:24 p.m., there was a wooden bench at the 1st floor stairwell J.

Based on observations, record review and interviews it was determined that the facility failed to provide safe storage for compressed gas. This resulted in the potential for oxygen tanks to tip over, possibly resulting in an unintentional discharge of compressed gas.. Findings include:

1. On January 10, 2011 at 2:07 p.m., there was an unsecured oxygen cylinder in the corridor by the Med Surg nurse's station.

Based on observations, record review and interviews it was determined that the facility failed to properly maintain the generator. This resulted in the potential for the lack of emergency electrical power. Findings include:

1. On January 11, 2011 at 5:00 a.m., all three generators were not vented 12 feet above grade.

2. On January 11, 2011 at 5:02 a.m., there were no battery powered lights at the generators.

3. On January 11, 2011 at 2:00 p.m., the facility added a 600 KW standby generator without benefit of permits or approval from the Office of State Fire Marshal Healthcare Unit.

Based on observations and interview it was determined that the facility failed to maintain the integrity of the electrical system. This resulted in the potential for injury to patients and staff. Findings include:

1. On January 11, 2011 at 8:05 a.m., The was a missing cover on the junction box in the 2nd floor sleeping room.

Based on observations, record review and interviews it was determined that the facility failed to ensure that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to residents & staff. Findings include:

1. On January 10, 2011 at 12:00 p.m., all three outlets (2p3b41) in treatment room #318 by sinks were not marked as protected by GFCI.

2. On January 10, 2010 at 1:20 p.m., there were outlets within 6' of the sinks in the Cascade Clinic reception bathroom, the OR Decon room, at the sink in Pre-op, in Scope room,and the waiting area across from room #324 that were not protected by GFCI.

3. On January 10, 2011 at 1:25 p.m., there was a relocatable power tap in room #329, at the Accounting printer, at the Administrator Assistants desk, in storage room 212, at the ICU nurse's station, in room 224 on computer cart, attached to TVs in rooms 241 and 242, on the nursery radio, on the computer on wheels in the nursery, in room #243, at nurse's station in Labor & Delivery, at nourishment station by cross corridor door R2058, in Recovery, at the nurse's station in ED, in the Lab, in Ultra Sound 1 & 2, in Mammography, in Nuclear Med, in R1001B, in the gift shop, main lobby, reception desk at the main entrance, to computers in Therapy, in massage therapy, in the Dialysis office, in pre-registration, in IT Director's office, and in the Vice President's office. Interview with Director of Plant Services indicated there are relocatable power taps throughout the facility.

4. On January 10, 2011 at 2:07 p.m., there was a non-patient care relocatable power tap in the Med-Surg corridor charging a med cart.

5. On January 10, 2011 at 2:11 p.m., there were computers on wheels with non-patient care relocatable power taps by Intensive Care Unit.

6. On January 10, 2011 at 2:24 p.m., there was a surge protector plugged into a relocatable power tap in Med Surg doctor's charting station.

7. On January 10, 2011 at 2:53 p.m., there was a toaster, microwave, and coffee maker in the clean utility room inside the Labor & Delivery Suite.

8. On January 10, 2011 at 3:12 p.m., the refrigerator in the Med Surg breakroom was plugged into a relocatable power tap.

9. On January 10, 2010 at 3:34 p.m., there was an extension cord being used in OR1 and OR3. There was a relocatable power tap at the computer in OR1 and OR2 and OR3.

10. On January 10, 2011 at 3:38 p.m., there was a relocatable power tap in the handwash area of the OR charging batteries.

11. On January 10, 2011 at 3:45 p.m., there was a relocatable power tap on a computer at the entrance to Recovery.

12. On January 10, 2011 at 4:17 p.m., there was a surge protector plugged into another surge protector on pop machines by the ED waiting room.

13. On January 10, 2011 at 4:53 p.m., there was a microwave and coffee maker plugged into a relocatable power tap in Radiology Tech area.

14. On January 11, 2011 at 8:02 a.m., there was an extension cord to the small dryer in the laundry room that went out the window.

15. On January 11, 2011 at 8:46 a.m., the electrical panel in Dialysis was blocked by storage.

16. On January 11, 2011 at 8:48 a.m., the cord was not inside cord restraints in the water treatment room for Dialysis.