HospitalInspections.org

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to separate sections of health care facilities from non-healthcare facilities.
This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 18/19.1.2.3, 18/19.1.1.4, 18/19.1.2.3).
Findings include, but are not limited to:
1. On 10/14/2015, at 11:37 a.m., there was missing fire proofing on the structural steel within the HVAC Plenum Room on Floor 2 within the '98 building.
2. On 10/14/2015, at 2:21 p.m., there was missing fire proofing on the structural steel within the IDF Closet that was behind the Housekeeping Room off Day Surgery Area within the '08 building.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to maintain the integrity of smoke separations for the building.
This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 18.3.6.1, .2, .5).
Findings include, but are not limited to:
1. On 10/14/2015, at 2:17 p.m., there was a door within the 2-hr. wall between the Main Lobby and Same Day Surgery Area that was not closing or latching completely. The door was adjacent to the Volunteer Desk within the '08 building.
2. On 10/14/2015, at 2:21 p.m., there was a door within the 2-hr. wall between the Main Lobby and Laboratory Area that was not closing or latching completely. The door was numbered 1391 and within the '08 building.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to install vertical openings that are capable of resisting the passage of fire and provide basic smoke compartmentation for the building.
This resulted in the potential for the spread of fire and smoke vertically in multi-story facilities 1 hour rating up to 3 stories, 2 hour exceeding 3 stories. (LSC 19.3.1.1, 8.2.5.1).
Findings include, but are not limited to:
1. On 10/14/2015, at 11:22 a.m., there was a door on the 2nd floor within the '90 building that was not closing or latching completely when tested by the surveyor and was protecting the Blue Elevator vertical shaft.
2. On 10/14/2015, at 11:59 a.m., the north leaf of the set of double doors on the 2nd floor within the '90 building that was not closing or latching completely when tested by the surveyor and was protecting the Red Elevator vertical shaft.
3. On 10/14/2015, at 3:58 p.m.,
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to provide a one hour separation between hazardous areas and the corridor for the building.
This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 19/18.3.2, 8.4).
Findings include, but are not limited to:
1. On 10/14/2015, at 12:36 p.m., the Oxygen Storage Room door within the '08 building was not closing and latching completely. Storage Room door was adjacent to Rm. 1127.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to maintain accessible exits for the building as required by 2000 NFPA 101, 19/18.2.2.2.4.
Per exception 1 of this code reference, this condition was only allowed when the clinical needs of the patients require specialized security measures for their safety. This resulted in the potential for panic and injury to occupants.
Findings include, but are not limited to:
1. On 10/13/2015, during record review between 10:00 a.m. and 5:00 p.m., the facility could not provide a current CMS accepted waiver letter for the stairs that were within an egress component on the Ground Floor adjacent to the Diagnostic Imaging Area. The exit is on the north side of the building.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Regional Satellite Safety Manager that the facility failed to maintain/test exit illumination on emergency power for a minimum of 30 second monthly and 90 minutes annually.
This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions (LSC 39.2.8, 39.2.9, 7.8, 7.9).
Findings include, but are not limited to:
1. On 10/15/2015, during record review at 10:50 a.m., there was no documentation showing the required annual 90 minute test on emergency lights within the facility. Last 90 minute test was conducted on 5/2014 and was past due since 5/2015.
Surveyor was accompanied by the Regional Satellite Safety Manager who acknowledged the existence of these conditions.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to provide fire drills for all staff affecting the entire building.
This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19/18.7.1.2, A.19/18.7.1.2).
Findings include, but are not limited to:
1. On 10/13/2015, during record review between 10:00 a.m. and 5:00 p.m., the facility had no documentation of conducting their 4th quarter night shift drill.
2. On 10/13/2015, during record review between 10:00 a.m. and 5:00 p.m., facility documentation presented to the surveyor by the facility showed that fire drills for night shift in 2014 and 2015 were not completed under varying conditions and random time throughout the shift.
Fire drills were conducted between 6:15 a.m. and 6:50 a.m. which demonstrates that fire drills were being conducted in a manner that created a pattern, instead of on different days and time and involving different locations and simulated circumstances.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition for the building.
This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6).
Findings include, but are not limited to:
1. On 10/13/2015, during record review between 10:00 a.m. and 5:00 p.m., weekly, monthly, and quarterly testing and maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the sprinklers to the adopted 1998 edition of NFPA 25 standards.
2. On 10/13/2015, at 2:05 p.m., there was a WiFi Router that was obstructing the spray pattern of a recessed automatic sprinkler head within OR #2.
3. On 10/14/2015, at 12:38 p.m., there was a painted automatic sprinkler head within the Laboratory Restroom in the '98 building that shall be replaced.
4. On 10/14/2015, at 2:39 p.m., there was missing automatic sprinkler protection under the stairs within the East Stairwell at the basement level in the '08 building.
5. On 10/14/2015, at 3:49 p.m., there was no spare stock of sidewall sprinkler heads for the facility. Facilities with 300-1000 sprinkler heads shall have a minimum stock of spare heads consisting of 12 heads or 2 of each type and temperature, whichever was greater.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Satellite Safety Manager that the facility failed to install fire extinguishers in accordance with adopted standards for the building.
This resulted in the potential for fires to progress beyond incipient stage (LSC 39.3.5, 4.6.12.1, 9.7.4.1, NFPA 10).
Findings include, but are not limited to:
1. On 10/15/2015, at 10:34 a.m., there was a fire extinguisher that was installed more than the maximum 60" from the finish floor. Fire extinguisher was located near the back of the Nurse Station.
Surveyor was accompanied by the Regional Satellite Safety Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to prohibit the use of portable space heating devices.
This resulted in the potential for ignition of nearby combustibles (LSC 19.7.8). Findings include, but are not limited to:
1. On 10/13/2015, at 2:21 p.m., there was a portable space heater (Dayton Heater) under the desk of the Nurse Station within the OR Corridor.
2. On 10/14/2015, at 12:14 p.m., there was a portable space heater (Dayton Heater) within Rm. 2335 within the '08 building.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" from 40" up to 80" above the floor for the building.
This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10, S&C).
Findings include, but are not limited to:
1. On 10/14/2015, at 12:07 p.m., there were computer charting stations attached to the corridor wall outside of Patient Rm. 224, Rm. 225, Rm. 232 and Rm. 234 that were not closing when opened by the surveyor. Charting stations were found within the '90 and '98 building.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interviews it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to provide safe storage for compressed gas.
This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks in universe. (LSC 19/18.3.2.4, NFPA 99 4.3.1.1.2).
Findings include, but were not limited to:
1. On 10/14/2015, at 11:42 a.m., there were 2-oxygen cylinders that were stored within Storage Rm. 2257 that had electrical outlets and switches within 60" of the finish floor.
2. On 10/14/2015, at 11:44 a.m., there was 1-oxygen cylinder that was stored within Storage Rm. 2255 that had electrical outlets and switches within 60" of the finish floor.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.
Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to provide safe storage for compressed gas for the facility.
This resulted in the potential for injury to staff and residents from a damaged compressed gas cylinder releasing unexpectedly. (LSC 19/18.3.2.4, NFPA 99 4.3.1.1.2).
Findings include, but were not limited to:
1. On 10/14/2015, at 3:52 p.m., there were 12-compressed gas cylinders that were not properly secured by evidence of a single chain at the top of the cylinder that would allow the bottoms of the cylinders to kick out and strike other cylinders or walls within the exterior LOX Compound during a seismic event.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with the Regional Satellite Safety Manager and Maintenance Assistant that the facility failed to provide safe storage for compressed gas.
This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks. (LSC 39.5.1, NFPA 70, NFPA 99 4.3.1.1.2).
Findings include, but were not limited to:
1. On 10/15/2015, at 11:30 a.m., there were compressed gas cylinders being stored within the Clean Supply Room that had electrical outlets and switches within 60" of the finish floor.
Surveyor was accompanied by the Regional Satellite Safety Manager and Maintenance Assistant who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to maintain smoke barrier fire resistance ratings when ducts penetrate smoke barriers throughout the building.
This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 18/19.3.7.3, 8.3.5, S&C 10-04-LSC).
Findings include, but are not limited to:
1. On 10/14/2015, during record review between 9:00 a.m. and 11:00 a.m., smoke and fire dampers throughout the facility were shown to be tested and inspected May 2009 and due for testing and maintenance in May 2015 according to facility maintenance program data (LS4.1-06 and LS4.1-06 Addendum).
The smoke and fire dampers had not been tested or there was no record of the completion of the testing and maintenance of the smoke and fire dampers at the time of the survey.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on record review and interviews it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to properly maintain the generator affecting the entire facility.
This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2).
Findings include, but are not limited to:
1. On 10/14/2015, during record review between 9:00 a.m. and 11:00 a.m., facility documentation provided to the surveyor showed that the required 3-year 4-hour load bank test for the facility generator did not meet requirements that were outlined within NFPA 110, 1999 edition which was the currently adopted edition as reference in the Life Safety Code, 2000 edition. Facility mentioned that they were using NFPA 110, 2005 edition to outline the load bank requirements.
2. On 10/14/2015, during record review between 9:00 a.m. and 11:00 a.m., documentation provided to the surveyor from the facility showed that the required weekly Electrolyte testing for the emergency generator was being completed monthly.
3. On 10/14/2015, during record review between 9:00 a.m. and 11:00 a.m., documentation provided to the surveyor from the facility showed that the required monthly specific gravity testing for the emergency generator was being completed quarterly.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for the building.
This resulted in the potential for injury to patients & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 10/13/2015, at 2:15 p.m., there were 2 relocatable power taps (RPT's) within OR #2 and OR #4 that were not in use and did not meet the required UL60601-1 standards for patient care areas.
2. On 10/13/2015, at 2:20 p.m., there were multiple relocatable power taps (RPT's) on the floor at the OR Scheduling Desk, within the Anesthesia Work Room and Anesthesia Office.
3. On 10/14/2015, at 11:24 a.m., there were multiple relocatable power taps (RPT's) on the floor within Rm. 2310, Rm. 209, Quality Risk Management Office and Med. Surg. Nurse Station.
4. On 10/14/2015, at 12:36 p.m., there was an electrical power supply capacitor that showed signs of overheating by discoloring on the face of the power supply within Rm. 1136.
5. On 10/14/2015, at 2:15 p.m., there were multiple relocatable power taps (RPT's) on the floor within Rm. 115 ('08 building) in Same Day Surgery and Office #1328.
6. On 10/14/2015, at 2:41 p.m., there were multiple relocatable power taps (RPT's) on the floor within the Film Storage Room ('08 building), Rm. 321, Diagnostic Imaging Director's Office, Rm. 313 ('08 building), Radiologists MRI Room, EMT Charting Room and Plant Operations Room.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Satellite Safety Manager that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for the building.
This resulted in the potential for injury to patients & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 10/15/2015, during the facility tour between 10:30 a.m. and 11:00 a.m., there were multiple relocatable power taps on the floor throughout the facility.
Surveyor was accompanied by the Regional Satellite Safety Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to separate sections of health care facilities from non-healthcare facilities.
This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 18/19.1.2.3, 18/19.1.1.4, 18/19.1.2.3).
Findings include, but are not limited to:
1. On 10/14/2015, at 11:37 a.m., there was missing fire proofing on the structural steel within the HVAC Plenum Room on Floor 2 within the '98 building.
2. On 10/14/2015, at 2:21 p.m., there was missing fire proofing on the structural steel within the IDF Closet that was behind the Housekeeping Room off Day Surgery Area within the '08 building.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to maintain the integrity of smoke separations for the building.
This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 18.3.6.1, .2, .5).
Findings include, but are not limited to:
1. On 10/14/2015, at 2:17 p.m., there was a door within the 2-hr. wall between the Main Lobby and Same Day Surgery Area that was not closing or latching completely. The door was adjacent to the Volunteer Desk within the '08 building.
2. On 10/14/2015, at 2:21 p.m., there was a door within the 2-hr. wall between the Main Lobby and Laboratory Area that was not closing or latching completely. The door was numbered 1391 and within the '08 building.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to install vertical openings that are capable of resisting the passage of fire and provide basic smoke compartmentation for the building.
This resulted in the potential for the spread of fire and smoke vertically in multi-story facilities 1 hour rating up to 3 stories, 2 hour exceeding 3 stories. (LSC 19.3.1.1, 8.2.5.1).
Findings include, but are not limited to:
1. On 10/14/2015, at 11:22 a.m., there was a door on the 2nd floor within the '90 building that was not closing or latching completely when tested by the surveyor and was protecting the Blue Elevator vertical shaft.
2. On 10/14/2015, at 11:59 a.m., the north leaf of the set of double doors on the 2nd floor within the '90 building that was not closing or latching completely when tested by the surveyor and was protecting the Red Elevator vertical shaft.
3. On 10/14/2015, at 3:58 p.m.,
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to provide a one hour separation between hazardous areas and the corridor for the building.
This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 19/18.3.2, 8.4).
Findings include, but are not limited to:
1. On 10/14/2015, at 12:36 p.m., the Oxygen Storage Room door within the '08 building was not closing and latching completely. Storage Room door was adjacent to Rm. 1127.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to maintain accessible exits for the building as required by 2000 NFPA 101, 19/18.2.2.2.4.
Per exception 1 of this code reference, this condition was only allowed when the clinical needs of the patients require specialized security measures for their safety. This resulted in the potential for panic and injury to occupants.
Findings include, but are not limited to:
1. On 10/13/2015, during record review between 10:00 a.m. and 5:00 p.m., the facility could not provide a current CMS accepted waiver letter for the stairs that were within an egress component on the Ground Floor adjacent to the Diagnostic Imaging Area. The exit is on the north side of the building.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Regional Satellite Safety Manager that the facility failed to maintain/test exit illumination on emergency power for a minimum of 30 second monthly and 90 minutes annually.
This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions (LSC 39.2.8, 39.2.9, 7.8, 7.9).
Findings include, but are not limited to:
1. On 10/15/2015, during record review at 10:50 a.m., there was no documentation showing the required annual 90 minute test on emergency lights within the facility. Last 90 minute test was conducted on 5/2014 and was past due since 5/2015.
Surveyor was accompanied by the Regional Satellite Safety Manager who acknowledged the existence of these conditions.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to provide fire drills for all staff affecting the entire building.
This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19/18.7.1.2, A.19/18.7.1.2).
Findings include, but are not limited to:
1. On 10/13/2015, during record review between 10:00 a.m. and 5:00 p.m., the facility had no documentation of conducting their 4th quarter night shift drill.
2. On 10/13/2015, during record review between 10:00 a.m. and 5:00 p.m., facility documentation presented to the surveyor by the facility showed that fire drills for night shift in 2014 and 2015 were not completed under varying conditions and random time throughout the shift.
Fire drills were conducted between 6:15 a.m. and 6:50 a.m. which demonstrates that fire drills were being conducted in a manner that created a pattern, instead of on different days and time and involving different locations and simulated circumstances.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition for the building.
This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6).
Findings include, but are not limited to:
1. On 10/13/2015, during record review between 10:00 a.m. and 5:00 p.m., weekly, monthly, and quarterly testing and maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the sprinklers to the adopted 1998 edition of NFPA 25 standards.
2. On 10/13/2015, at 2:05 p.m., there was a WiFi Router that was obstructing the spray pattern of a recessed automatic sprinkler head within OR #2.
3. On 10/14/2015, at 12:38 p.m., there was a painted automatic sprinkler head within the Laboratory Restroom in the '98 building that shall be replaced.
4. On 10/14/2015, at 2:39 p.m., there was missing automatic sprinkler protection under the stairs within the East Stairwell at the basement level in the '08 building.
5. On 10/14/2015, at 3:49 p.m., there was no spare stock of sidewall sprinkler heads for the facility. Facilities with 300-1000 sprinkler heads shall have a minimum stock of spare heads consisting of 12 heads or 2 of each type and temperature, whichever was greater.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Satellite Safety Manager that the facility failed to install fire extinguishers in accordance with adopted standards for the building.
This resulted in the potential for fires to progress beyond incipient stage (LSC 39.3.5, 4.6.12.1, 9.7.4.1, NFPA 10).
Findings include, but are not limited to:
1. On 10/15/2015, at 10:34 a.m., there was a fire extinguisher that was installed more than the maximum 60" from the finish floor. Fire extinguisher was located near the back of the Nurse Station.
Surveyor was accompanied by the Regional Satellite Safety Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to prohibit the use of portable space heating devices.
This resulted in the potential for ignition of nearby combustibles (LSC 19.7.8). Findings include, but are not limited to:
1. On 10/13/2015, at 2:21 p.m., there was a portable space heater (Dayton Heater) under the desk of the Nurse Station within the OR Corridor.
2. On 10/14/2015, at 12:14 p.m., there was a portable space heater (Dayton Heater) within Rm. 2335 within the '08 building.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" from 40" up to 80" above the floor for the building.
This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10, S&C).
Findings include, but are not limited to:
1. On 10/14/2015, at 12:07 p.m., there were computer charting stations attached to the corridor wall outside of Patient Rm. 224, Rm. 225, Rm. 232 and Rm. 234 that were not closing when opened by the surveyor. Charting stations were found within the '90 and '98 building.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interviews it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to provide safe storage for compressed gas.
This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks in universe. (LSC 19/18.3.2.4, NFPA 99 4.3.1.1.2).
Findings include, but were not limited to:
1. On 10/14/2015, at 11:42 a.m., there were 2-oxygen cylinders that were stored within Storage Rm. 2257 that had electrical outlets and switches within 60" of the finish floor.
2. On 10/14/2015, at 11:44 a.m., there was 1-oxygen cylinder that was stored within Storage Rm. 2255 that had electrical outlets and switches within 60" of the finish floor.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.
Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to provide safe storage for compressed gas for the facility.
This resulted in the potential for injury to staff and residents from a damaged compressed gas cylinder releasing unexpectedly. (LSC 19/18.3.2.4, NFPA 99 4.3.1.1.2).
Findings include, but were not limited to:
1. On 10/14/2015, at 3:52 p.m., there were 12-compressed gas cylinders that were not properly secured by evidence of a single chain at the top of the cylinder that would allow the bottoms of the cylinders to kick out and strike other cylinders or walls within the exterior LOX Compound during a seismic event.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with the Regional Satellite Safety Manager and Maintenance Assistant that the facility failed to provide safe storage for compressed gas.
This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks. (LSC 39.5.1, NFPA 70, NFPA 99 4.3.1.1.2).
Findings include, but were not limited to:
1. On 10/15/2015, at 11:30 a.m., there were compressed gas cylinders being stored within the Clean Supply Room that had electrical outlets and switches within 60" of the finish floor.
Surveyor was accompanied by the Regional Satellite Safety Manager and Maintenance Assistant who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to maintain smoke barrier fire resistance ratings when ducts penetrate smoke barriers throughout the building.
This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 18/19.3.7.3, 8.3.5, S&C 10-04-LSC).
Findings include, but are not limited to:
1. On 10/14/2015, during record review between 9:00 a.m. and 11:00 a.m., smoke and fire dampers throughout the facility were shown to be tested and inspected May 2009 and due for testing and maintenance in May 2015 according to facility maintenance program data (LS4.1-06 and LS4.1-06 Addendum).
The smoke and fire dampers had not been tested or there was no record of the completion of the testing and maintenance of the smoke and fire dampers at the time of the survey.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on record review and interviews it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to properly maintain the generator affecting the entire facility.
This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2).
Findings include, but are not limited to:
1. On 10/14/2015, during record review between 9:00 a.m. and 11:00 a.m., facility documentation provided to the surveyor showed that the required 3-year 4-hour load bank test for the facility generator did not meet requirements that were outlined within NFPA 110, 1999 edition which was the currently adopted edition as reference in the Life Safety Code, 2000 edition. Facility mentioned that they were using NFPA 110, 2005 edition to outline the load bank requirements.
2. On 10/14/2015, during record review between 9:00 a.m. and 11:00 a.m., documentation provided to the surveyor from the facility showed that the required weekly Electrolyte testing for the emergency generator was being completed monthly.
3. On 10/14/2015, during record review between 9:00 a.m. and 11:00 a.m., documentation provided to the surveyor from the facility showed that the required monthly specific gravity testing for the emergency generator was being completed quarterly.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Manager and Maintenance Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for the building.
This resulted in the potential for injury to patients & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 10/13/2015, at 2:15 p.m., there were 2 relocatable power taps (RPT's) within OR #2 and OR #4 that were not in use and did not meet the required UL60601-1 standards for patient care areas.
2. On 10/13/2015, at 2:20 p.m., there were multiple relocatable power taps (RPT's) on the floor at the OR Scheduling Desk, within the Anesthesia Work Room and Anesthesia Office.
3. On 10/14/2015, at 11:24 a.m., there were multiple relocatable power taps (RPT's) on the floor within Rm. 2310, Rm. 209, Quality Risk Management Office and Med. Surg. Nurse Station.
4. On 10/14/2015, at 12:36 p.m., there was an electrical power supply capacitor that showed signs of overheating by discoloring on the face of the power supply within Rm. 1136.
5. On 10/14/2015, at 2:15 p.m., there were multiple relocatable power taps (RPT's) on the floor within Rm. 115 ('08 building) in Same Day Surgery and Office #1328.
6. On 10/14/2015, at 2:41 p.m., there were multiple relocatable power taps (RPT's) on the floor within the Film Storage Room ('08 building), Rm. 321, Diagnostic Imaging Director's Office, Rm. 313 ('08 building), Radiologists MRI Room, EMT Charting Room and Plant Operations Room.
Surveyor was accompanied by the Plant Operations Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Satellite Safety Manager that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for the building.
This resulted in the potential for injury to patients & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 10/15/2015, during the facility tour between 10:30 a.m. and 11:00 a.m., there were multiple relocatable power taps on the floor throughout the facility.
Surveyor was accompanied by the Regional Satellite Safety Manager who acknowledged the existence of these conditions.