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Based on observations and interview it was determined 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 19.1.2.3, 19.1.1.4). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 10:00 a.m., the facility did not have a complete set of current fire and life safety drawings of the building, including proper separation between the hospital and MOB, and identification of suites.

2. On August 29, 2011 at 10:00 a.m., the Laundry area was listed as a suite on the 7/18/01 Life Safety Summary for the West Wing Addition and other "non-suites".

3. On August 30, 2011 at 9:15 a.m., the facility did not have a certificate of occupancy from the local building official to use the shell space as a storage/shop area.

Based on observations and interviews it was determined that the facility failed to meet or maintain the construction type requirements. This resulted in the potential for fire/smoke to spread to other areas of the facility, causing the exposure of patients & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 30, 2011 at 5:28 p.m., utilities serving more than the two-hour exit passageway were found above the ceiling tiles in the Administration area.

Based on observations and interviews it was determined that the facility failed to maintain integrity of smoke separations. This resulted in the potential for smoke to spread to other areas of the facility, causing the exposure of patients & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 4:34 p.m., unsealed wall penetrations were found over the cross-corridor doors at the 3 N Nurse's Station, including unfinished patchwork near the duct.

2. On August 29, 2011 at 5:21 p.m., unsealed wall penetrations were found in the 3rd Floor Stairwell and in the Pharmacy North store room.

3. On August 30, 2011 at 11:43 a.m., there was a gap around the conduit that was not sealed in the Environmental Storage Room.

4. On August 30, 2011 at 5:27 p.m., unsealed wall penetrations and exposed screws were found above the cross-corridor doors in the Administration area.

5. On August 30, 2011 at 5:33 p.m., there were unsealed wall penetrations above the Medical Records area in the corridor.

Based on observations, record review and interviews it was determined that the facility failed to maintain exit corridor doors to resist the passage of smoke in accordance with NFPA 80. This resulted in the potential for passage of smoke into the means of egress in the event of a hostile fire event (LSC 19.2.3.5, 19.3.6.3, 4.6.12.1). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 10:00 a.m., the facility did not have documentation of maintaining smoke doors monthly. Per interview with the Maintenance Director, only fire doors were checked monthly.

2. On August 29, 2011 at 10:00 a.m., the facility did not have access to NFPA 80 (1999) for maintaining smoke and fire doors.

3. On August 29, 2011 at 4:32 p.m., the cross-corridor doors by the 3 North Nurse's Lounge did not close and latch properly.

4. On August 30, 2011 at 8:55 a.m., there were kick-down door props installed on the cross-corridor doors outside the Old Outpatient Surgery area.

Based on observations, interviews 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 (LSC 19.7.1.1) Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 5:30 p.m., the East Stairwell access doors from floors 1, 2, and 3 were not signed as "not an exit".

2. On August 30, 2011 at 9:52 a.m., there were no illuminated exit signs at the egress court by the Old Ambulance Bays.

3. On August 30, 2011 at 4:35 p.m., the exit doors of the Electrical Room 2000 were not properly signed as exits.

4. On August 30, 2011 at 5:07 p.m., the doors to the Service Corridor were not signed as "not an exit".

Based on observations and interview it was determined that the facility failed to provide opening protection, which separates exit corridors from hazardous areas with a sprinkler and smoke partition in existing facilities (Ch. 19). This resulted in the potential for the spread of fire/smoke into other portions of the facility including the means of egress during a hostile fire event (LSC 19.3.2.6, 8.2.3.2, 7.2.1.8, 19.3.2.1). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 4:45 p.m., the linen closet across from the Patient Care Manager's Office in the OB wing did not have self-closing doors.

2. On August 30, 2011 at 6:30 a.m., OR 6 had been converted to a storage room and an automatic closer was not installed on the door.

3. On August 30, 2011 at 11:42 a.m., the door separating the Mechanical Room from the Dietary area had an excessive gap at the bottom.

4. On August 30, 2011 at 4:24 p.m., there was combustible storage in the 1911 Electrical Room.

5. On August 30, 2011 at 4:32 p.m., the South exit door of the Electrical Room 2000 did not swing in the proper direction.

Based on observations, record review and interviews it was determined that the facility failed to install/ maintain exit access and exit doors with an approved clear width to accommodate occupants served. This resulted in the potential for panic and injury to patients & staff during emergency evacuations and relocation (LSC 18.2.3.5). Findings include, but are not limited to:

1. On August 29, 2011 at 5:30 p.m., the newly-installed exit door leading from 3 East to the MOB did not measure 41 1/2-inches in clear width. The door was installed without approval from OSFM. This same condition was found on the 2nd Floor.

Based on observations and interview it was determined that the facility failed to ensure that required battery-powered emergency lighting was tested annually. This resulted in the potential for confusion and panic by patients & staff during emergency conditions (LSC 19.2.8). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 10:00 a.m., the facility had no documentation of testing the batteries of the emergency lights throughout the building every month, or replacing the batteries on an annual basis.

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 (LSC 19.2.10). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 30, 2011 at 10:20 a.m., improperly oriented exit signs were found at the Reception Desk by the Surgery/ED entrance.

2. On August 30, 2011 at 10:50 a.m., the exit sign at the Patient Registration double-doors West of the Patient Financial office was improperly oriented.

Based on observations, interviews and record review it was determined that the facility failed to maintain emergency action plan current & readily available. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 30, 2011 at 6:29 p.m., the facility's Emergency Preparedness Manual from the Switchboard did not include the following information: There was no annually updated hazard/risk assessment of the facility; many of the procedures were generic to the corporation, not building specific; the fire watch policy did not include notification to the OSFM Healthcare Unit if the fire alarm or fire sprinkler systems were out for more than four hours; the call back rosters were dated 2010; and the fire alarm/drill log contained incomplete information.

Based on record reviews and interviews it was determined that the facility failed to provide fire drills 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 (LSC 19.7.1.2, A.19.7.1.2). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 10:00 a.m., there was no documentation of fire drills during the night shift (11 pm - 7:30 am) in 2010, and only on 8/10/11 in 2011.

Based on observations, record review and interviews it was determined that the facility failed to install fire alarm system in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 19.3.4, 9.6). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 4:57 p.m., the fire alarm pull station next to the Soiled Utility Room in the OB Ward was mounted more than 54-inches from the floor to the handle. During the survey, this condition was also found in the OB Operating Room corridor, at the 59 Elevator, by the Risk Manager's Office, in the OR Corridor of the old building, in the Old Outpatient Surgery area, by the CCU elevator, and outside the Ultrasound Waiting Room.

2. On August 30, 2011 at 9:02 a.m., a smoke detector was missing in the CCU Family Room, where there was evidence of people sleeping with blankets and pillows on the couches.

3. On August 30, 2011 at 10:00 a.m., notification appliances were found to be installed in the four patient sleep-study rooms.

4. On August 30, 2011 at 10:05 a.m., a sign was missing indicating the location of the Fire Alarm Control Panel (FACP) in the Electrical Room.

5. On August 30, 2011 at 10:26 a.m., horn-strobes were found in the Public Restrooms by the Surgery/ED Lobby.

6. On August 30, 2011 at 10:39 a.m., notification appliances were found in the X-Ray rooms.

7. On August 30, 2011 at 4:58 p.m., the fire alarm detection installed near the Autoclave machines was improper, creating false alarms.

Based on observations, record review and interviews it was determined that the facility failed to test and maintain fire alarm in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 10:00 a.m., the fire alarm smoke detector sensitivity report dated 1/25/11 indicated a sensitivity range of .6-1.8 for detectors, which did not match the report from 1/26/10 that indicated a range of .72-2.5. Neither form indicated the range that the alarm tested at.

2. On August 29, 2011 at 10:00 a.m., the facility did not have access to NFPA 72 (1999) for maintaining the fire alarm system. The facility also did not have documentation of technician competence for staff to test the fire alarm system per NFPA 72.

3. On August 29, 2011 at 10:00 a.m., the fire alarm annual service report, dated 7/19/11, indicated that the devices located in the Surgery area were not tested at that time, and that the service company would return in October to complete the service.

4. On August 30, 2011 at 9:00 a.m., the glass bulb in the fire alarm pull station was missing at the CCU Nurse's Station, as well as by the 2 N elevators.

Based on observations and interview it was determined that the facility failed to ensure that there was complete sprinkler coverage in accordance with NFPA 13 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 (LSC 19.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 4:01 p.m., the fire sprinkler coverage in the Mechanical 5 Penthouse was incomplete.

2. On August 29, 2011 at 5:04 p.m., the spacing of fire sprinkler heads in the bathroom of Room 306 was less than 60-inches.

3. On August 29, 2011 at 5:14 p.m., there was no fire sprinkler coverage in the 1, 2 & 3 East Communications Closets.

4. On August 30, 2011 at 9:05 a.m., the electrical closet near Bio-Med was not protected by fire sprinklers. This condition was also found in the electrical closet next to the ECHO Reading Room.

5. On August 30, 2011 at 10:44 a.m., a fire sprinkler located in a small storage room across from the Patient Financial Counselor's office was improperly installed.

6. On August 30, 2011 at 11:02 a.m., there was a missing escutcheon plate in the restroom in the Lab Waiting area.

7. On August 30, 2011 at 11:23 a.m., the Ultra Sound Tech Room was not protected by fire sprinklers.

8. On August 30, 2011 at 11:29 a.m., the fire sprinkler protecting the Medical Records Storage Room on the first floor was capped off.

9. On August 30, 2011 at 11:51 a.m., there was no fire sprinkler protection underneath the stairs in the Main Entrance Lobby.

10. On August 30, 2011 at 12:04 p.m., the fire department connection (FDC) for the facility's fire sprinkler systems were blocked from view from the road by parked vehicles and were not marked by a red and white sign with a minimum of 6-inch block letters indicating that they were FDCs.

11. On August 30, 2011 at 12:05 p.m., the fire department connections were not properly signed to indicate which part of the building they served.

12. On August 30, 2011 at 12:10 p.m., the fire department connection at the west end of the building was not properly signed as an FDC (red/white sign with minimum of 6-inch block letters) and was blocked by vegetation.

13. On August 30, 2011 at 4:25 p.m., the spacing of fire sprinkler heads in the 1911 Electrical Room were less than 60-inches.

14. On August 30, 2011 at 4:48 p.m., the fire sprinklers in the Laundry Wash Room were more than 24-inches below the ceiling.

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 (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 10:00 a.m., there was no documentation of a forward flow test of the backflow preventer device, including a graph of pressure and gallons per minute for the system demand and available water. There was also no documentation of the five-year, III-C test.

2. On August 29, 2011 at 10:00 a.m., the facility did not have access to NFPA 25 (1998) for maintaining the fire sprinkler system. Nor did they have documentation of technician competence for staff to test the sprinkler system per NFPA 25.

3. On August 29, 2011 at 10:00 a.m., there was no documentation of testing the fire sprinkler tamper switches or conducting the quarterly flow test.

4. On August 29, 2011 at 10:00 a.m., maintenance documents indicated that the fire sprinkler system tamper switches were being tested every six months, rather than monthly.

5. On August 30, 2011 at 8:57 a.m., two fire sprinkler heads were found painted in the CCU restroom and in the System Analyst Office.

6. On August 30, 2011 at 9:17 a.m., a corroded fire sprinkler head was found in the Shell Space.

7. On August 30, 2011 at 9:54 a.m., damaged and corroded fire sprinkler heads were found covering the exterior near the Old Ambulance Bays and dirty fire sprinkler heads were found in the Lab..

8. On August 30, 2011 at 5:11 pm, the spare fire sprinkler storage box did not contain at least two of each type of head in the facility, and an overall total of at least 24 spare heads. The wrench for changing heads was also missing.

9. On August 30, 2011 at 10:30 a.m., a loose escutcheon plate was found outside the SC entrance and there was a missing escutcheon plate in the Lab waiting area..

Based on observations and interview it was determined that the facility failed to maintain fire extinguishers. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 10:00 a.m., the facility did not have access to NFPA 10 (1998) for maintaining fire extinguishers.

2. On August 29, 2011 at 4:36 p.m., the fire extinguisher by the restroom across the hall from the East door of OB North Wing was mounted over 60-inches from the floor to the handle.

3. On August 30, 2011 at 11:58 a.m., there was no fire extinguisher located at the Helipad per NFPA 418, Standard for Heliports.

4. On August 30, 2011 at 4:29 p.m., the fire extinguisher in the Telecom Room was not marked as being inspected in March 2011, as part of routine maintenance.

Based upon record reviews, observations and interviews it was determined that the facility failed to ensure safe smoking practices by residents in the facility in accordance with facility policies and life safety regulations. This resulted in the potential for exposing residents to a fire and/or smoke environment (LSC 19.7.4). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 30, 2011 at 11:55 a.m., improperly discarded cigarette butts were found in the combustible landscaping and garbage can near the Main Entrance. Per the facility policy, the campus is non-smoking.

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 and harm to staff (LSC 19.5.2.1, 19.5.2.2, 9.2, NFPA 90A). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 30, 2011 at 6:10 p.m., there were no refrigerant leak notification appliances at any of the four entrances to the Chiller Room.

Based on observations and interview it was determined that the facility failed to maintain an approved ventilation hood and duct system. This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 4.6.12.1, 9.2.3, 19.3.2.6, NFPA 96 A.1.1.4, UL300). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 30, 2011 at 5:44 p.m., the hood suppression system pull station in the Kitchen was obstructed by a counter and inaccessible.

2. On August 30, 2011 at 5:45 p.m., the cooking areas in the Kitchen and Cafeteria had excessive grease buildup on the appliances and ductwork, including the fire suppression system equipment. The hood cleaning report indicated that the last service was on 1/12/11 and has been past due since 7/12/11.

3. On August 30, 2011 at 5:48 p.m., the hood suppression system pull station in the Cafeteria was closer than 10-20 feet to the cooking appliances.

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, but are not limited to:

1. On August 30, 2011 at 9:24 a.m., a space heater was found in the Medical Staff Break Room.

Based on observations and interview it was determined that the facility failed to ensure that exit egress remained clear and unobstructed. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency. Findings include, but are not limited to:

1. On August 29, 2011 at 4:13 p.m., an unattended linen cart was found blocking the corridor at Room 328.

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 (LSC 19.7.5.4). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 4:25 p.m., a foam-based plant was found on the counter at the Pediatric Nurse's Station and in the Surgery Lobby.

Based upon observations and interviews it was determined that the facility failed to ensure that no storage of highly flammable character existed in the corridors. This resulted in the potential for excessive fire spread (LSC 19.7.5.5, Exhibit 19.23). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 4:13 p.m., an unattended linen cart was found at Room 328.

Based on observations, record review and interviews it was determined that the facility failed to provide safe storage for compressed gas (for light switch in oxygen storage room/ref. NFPA 99, A-4-3.1.1.2(a)2 #4). This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks and the secure storage of compressed gas (LSC 19.3.2.4, 4.3.1.1.2). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 30, 2011 at 6:30 a.m., oxygen cylinders were stored in the OR Storage and in the CCU Storage, where the electrical outlets and switches were within 60-inches of the floor.

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 tank to tip over, possibly resulting in an unintentional discharge of compressed gas. (LSC 19.3.2.4, 4.3.1.1.2). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

2. On August 30, 2011 at 4:15 p.m., a helium tank in the Gift Shop was found unsecured.

3. On August 30, 2011 at 4:35 p.m., a large compressed gas tank was not properly secured in the Mechanical Room 4.

Based on observations, record review and interviews it was determined that the facility failed to ensure that piped in medical gas systems comply with NFPA 99. This resulted in the potential for injury to patients during medical procedures. Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include but are not limited to:

1. On August 30, 2011 at 6:03 p.m., there was no curb containment established for the liquid oxygen area, including the dispensing location for the delivery truck.

Based on observations, record review and interviews it was determined that the facility failed to ensure anesthetizing locations were protected in accordance with NFPA 99, 5-4.1, ASHRAE Standard 170. This resulted in the potential for injury to patients during medical procedures. Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 3:15 p.m., records for the facility indicated multiple days where the humidity levels in the Operating Rooms were below the allowable 30%-60% threshold for performing procedures. Per interview, the facility does not have a policy for shutting down the Operating Rooms if humidity levels are outside of the acceptable range. Examples of unacceptable readings include: 8/18/11- ORs 1, 2, 3, 4, 5, & 6 = 21%, 8/17/11- ORs 2, 4, & 6 = 21%, 4/29/11- ORs 2, 4, & 6 = 15%, 4/28/11- ORs 2, 4, & 6 = 19%, 4/11/11- ORs 2, 4, & 6 = 12%, 4/9/11- ORs 1, 3, & 5 = 14%, 4/9/11- ORs 2, 4, & 6 = 11%.

Based on observations, record review and interviews it was determined that the facility failed to provide the required emergency lighting for procedure rooms. This resulted in the potential for the loss of power during surgical procedures ( NFPA 99, 3-3.2.1.2(5)(e). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 4:58 p.m., there was no battery-powered emergency light found in the OB Operating Room 1.

Based on observations and interview it was determined that the facility failed to post occupant load signs for Assembly Occupancies. This resulted in the potential for overcrowding of Assembly Rooms and spaces (LSC 12.1.7). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

2. On August 30, 2011 at 5:06 p.m., there was no occupant load sign for the Snake River Conference Room. This condition also existed in the Conference Meeting Room 3.

Based on observations and interviews it was determined that the facility failed to store flammable & combustible liquids in an approved manner. This resulted in the potential for flammable fumes in uncontrolled areas (LSC 10.7.2.1, NFPA 99, NFPA 45, NFPA 30). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 30, 2011 at 9:13 a.m., flammable liquids were not stored in a flammable liquids cabinet in the Shell Space.

Based on observations, record review and interviews it was determined that the facility failed to perform required maintenance inspection of the medical gas system. This resulted in the potential for failure of the medical gas system (NFPA 99, Ch. 4) Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 10:00 a.m., the facility was past-due for the annual certification of the medical gas system (last recorded 8/5/10).

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 (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2) Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 10:00 a.m., documentation of the emergency generator indicated that the three-year, four-hour load bank test at 80% was past due. There was only documentation of a two-hour test being conducted at 30%.

2. On August 29, 2011 at 10:00 a.m., the facility did not have access to NFPA 110 (1999) for maintaining the emergency generator. The facility also did not have documentation of technician competence for staff to test the emergency generator per NFPA 110.

3. On August 30, 2011 at 5:50 a.m., the emergency shut-off switch for the generator was not located outside of the Generator 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 (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 10:00 a.m., the facility's electrical equipment policy indicates that items are only to be checked when new, not on a regular maintenance schedule.

2. On August 29, 2011 at 3:57 p.m., an open junction box was found in the Mechanical 6 Penthouse.

3. On August 29, 2011 at 4:15 p.m., a non-patient approved relocatable power tap was found in the Pediatric Playroom by Room 326 and attached to the cart at the OB nurse station.

4. On August 29, 2011 at 4:23 p.m., electrical outlets in the 3 North Nurse's Station, at the sink in the Soiled Utility room, in the OB Ward, in the storage closet of the OB Operating Room, and the sink in the Pharmacy were not GFCI protected.

5. On August 29, 2011 at 4:30 p.m., household-use appliances were found in the 3 North Staff Break Room.

6. On August 29, 2011 at 4:46 p.m., a relocatable power tap was found in the Patient Care Manager's Office in the OB wing and on the floor at the nurse station across from Birthing Room #304.

7. On August 29, 2011 at 5:06 p.m., a household-rated microwave was found in the OB Break room. A relocatable power tap was also being used in the room.

8. On August 29, 2011 at 5:19 p.m., a household-rated microwave, relocatable power tap and space heater were found in the Clinical Quality Analyst's Office.

9. On August 29, 2011 at 5:22 p.m., extension cords and relocatable power taps were found interconnected throughout the Pharmacy, including near the PYXIS machine and the TPN Compounder. A household-rated coffee maker was also found in this area.

10. On August 30, 2011 at 6:16 a.m., non-patient-rated relocatable power taps were found at the computer and on a cart in ORs 1, 2, 3 & 4.

11. On August 30, 2011 at 6:26 a.m., a relocatable power tap was found in the Sterile Core at the computer.

12. On August 30, 2011 at 6:35 a.m., there were no GFCI outlets found in the OB Nursery. There were also broken electrical outlets on a wire mold.

13. On August 30, 2011 at 6:43 a.m., a non-patient-rated relocatable power tap was found at the computers in Endoscopy Procedure Rooms 1 & 2.

14. On August 30, 2011 at 6:50 a.m., a household-rated microwave was found in the OR Staff Lounge.

15. On August 30, 2011 at 8:50 a.m., relocatable power taps were found in the Emergency Command Center (marked at Room 240).

16. On August 30, 2011 at 8:51 a.m., there were no GFCI outlets at the Nurse's Station in the Old Outpatient Surgery area, as well as the room next to 249.

17. On August 30, 2011 at 8:58 a.m., a relocatable power tap was found at the Charting Station in CCU.

18. On August 30, 2011 at 9:01 a.m., a non-patient-rated relocatable power tap was found mounted on an IV cart in CCU. This same condition was also found in Room 231.

19. On August 30, 2011 at 9:04 a.m., daisy-chained relocatable power taps were found in the Bio-Med area.

20. On August 30, 2011 at 9:08 a.m., an open junction box was found in the Sterilizer Room.

21. On August 30, 2011 at 9:11 a.m., extension cords were found serving a table saw in the Shell Space.

22. On August 30, 2011 at 9:24 a.m., a space heater was found plugged into an relocatable power tap in the Medical Staff Break Room. There was also a non-listed candle warmer and a household-rated microwave in use.

23. On August 30, 2011 at 9:30 a.m., a household-rated microwave and relocatable power tap were found in the Systems Analyst office. There was also a household-rated microwave in the Nurse Manager's office.

24. On August 30, 2011 at 9:56 a.m., a household-rated microwave, toaster, and coffee maker were found in the Sleep Center. There were also relocatable power taps in use.

25. On August 30, 2011 at 10:04 a.m., a relocatable power tap was found in the MRI observation area.

26. On August 30, 2011 at 10:11 a.m., GFCI outlets were missing in the room across from the ED Lounge and ED Staff Lounge.

27. On August 30, 2011 at 10:12 a.m., a 6-2 electrical outlet adapter was found in the Physician's Room.

28. On August 30, 2011 at 10:16 a.m., a relocatable power tap was found at the Kiosk in the Surgery Lobby.

29. On August 30, 2011 at 10:42 a.m., a relocatable power tap was found in the Patient Financial Counselor's office.

30. On August 30, 2011 at 11:03 a.m., a household-rated microwave was found in the Lab Staff Lounge.

31. On August 30, 2011 at 11:15 am, there were no GFCI outlets found in the Lab near the sinks.

32. On August 30, 2011 at 11:19 a.m., relocatable power taps and household-rated microwaves were found in Patient Accounts.

33. On August 30, 2011 at 11:22 a.m., a microwave and refrigerator were found plugged into a relocatable power tap in the Ultrasound Tech Room.

34. On August 30, 2011 at 11:31 a.m., non-patient-rated relocatable power taps were found on the first floor in the MRI area, across from Diagnostic Respiratory Care.

35. On August 30, 2011 at 11:33 a.m., a household-rated microwave was plugged into a relocatable power tap in the Diagnostic Respiratory Care area. There were also exposed wires on the relocatable power tap.

36. On August 30, 2011 at 11:46 a.m., an electrical outlet adapter was found in the Lock & Key Room.

37. On August 30, 2011 at 11:49 a.m., a broken electrical outlet cover was found in the Foundation Volunteer's Office.

38. On August 30, 2011 at 4:16 p.m., non-commercially-rated holiday lights were found plugged into a relocatable power tap in the Gift Shop.

39. On August 30, 2011 at 4:21 p.m., a wax-warmer in use and on display in the Gift Shop was not approved by a recognized regulatory agency.

40. On August 30, 2011 at 4:24 p.m., there was a broken electrical outlet in the 1911 Electrical Room.

41. On August 30, 2011 at 4:36 p.m., there were daisy-chained relocatable power taps in the Materials area.

42. On August 30, 2011 at 4:52 p.m., a household-rated microwave was found in the Sterile Processing area.

43. On August 30, 2011 at 4:59 p.m., there were no GFCI outlets installed in the Chemical Storage area. This condition also existed in the Snake River Conference Room.

44. On August 30,2011 at 5:37 p.m., a household-rated microwave and relocatable power taps were found in the Medical Records area.

45. On August 30, 2011 at 6:10 p.m., the outlet within 5-feet of the sink in the Boiler Room was not GFCI protected.

Based on record review and interviews it was determined that the facility failed to have a plan to address either a planned or unplanned fire sprinkler system shutdown that identified their procedures to follow when the fire sprinkler system was unavailable. This potentially prevents early notification of smoke &/or fire that delays evacuation of patients & staff to a safe refuge. Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 10:00 a.m., the facility did not have a policy for conducting a fire watch if the fire sprinkler system was shut down for more than four-hours, including notification to OSFM.

Based on record review and interviews it was determined that the facility failed to have a plan to address either a planned or unplanned fire alarm system shutdown that identified their procedures to follow when the fire alarm system was unavailable. This potentially prevents early notification of smoke &/or fire that delays evacuation of patients & staff to a safe refuge. Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 29, 2011 at 10:00 a.m., the facility did not have a policy for conducting a fire watch if the fire alarm system was shut down for more than four-hours, including notification to OSFM.