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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 or exit passageways. This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 19/18.1.2.3, 19/18.1.1.4, 19.1.2.3). Findings include, but are not limited to:

1. On December 6, 2011 at 7:30 p.m., the 90 minute rated fire doors in the 2 hour rated wall were propped open with a wedge at the entrance to the PNS building from the skybridge. The wall above the doors at this location were also found to be incomplete on the skybridge side to provide the 2 hour separation.

2. On December 7, 2011 at 8:23 a.m., there were 2 unsealed penetrations at the 1 hour suite separation to the Respiratory Care from the corridor on 2 Ancillary.

3. On December 7, 2011 at 8:48 a.m., the IT stockroom door in Outpatient Infusion was not equipped with an automatic closer and was a 90 minute rated door.

4. On December 7, 2011 at 9:00 a.m., the 2 main exit stairwell, which was a 2 hour rated exit passageway, contained plumbing, electrical, HVAC that were not serving the stairwell.

5. On December 7, 2011 at 9:53 a.m., the 2 hour wall was incomplete at the 90 minute door by the security hallway in the main lobby.

6. On December 7, 2011 at 9:55 a.m., the 2 hour exit passageway at the kitchen was incomplete from the stairs to the exterior for the entire passageway. There were unauthorized openings in the 2 hour passageway as well that included the electrical panels, an unattended housekeeping closet, and a mail slot. The walls were not to structure in the 2 hour passageway.

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

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 19/18.2.3.5, (Table 18.3.2.1), 19/18.3.6.3.1 Ex 2, 4.6.12.1, A19.3.6.3.3). Findings include, but are not limited to:

1. On December 6, 2011 at 3:30 p.m., the facility was not testing and inspecting all fire and smoke doors in the facility periodically in accordance with NFPA 80, the following doors were found inoperable: cross corridor doors at 4 north by the neuro psych testing, 4 South entrance doors at the elevator lobby, 3 South entrance doors at the elevator lobby,

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

Based on observations and interview it was determined that the facility failed to provide adequate exit illumination to the public way with bulbs arranged so that if one bulb burned out there would still be adequate exit lighting. This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions (LSC 19/18.2.8). Findings include, but are not limited to:

1. On December 7, 2011 at 10:30 a.m., there were not 2 bulbs at the exterior exit lighting of the auditorium.

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

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 19/18.2.10). Findings include, but are not limited to:

1. On December 7, 2011 at 10:50 a.m., there was an improperly located exit sign near the entrance to the Johnson unit that was installed on an exterior door and not at the double cross corridor doors leaving the unit. The exterior door did not indicate "not an exit". The exterior path did not meet minimum egress requirements for width and lighting.

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

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 19/18.7.1.1). Findings include, but are not limited to:

1. On December 6, 2011 at 4:00 p.m., there were not printed out emergency preparedness/ disaster plans located at all nurse stations, immediately available to all staff. Plans were only available on the computer.

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

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 19/18.7.1.2, A.19/18.7.1.2). Findings include, but are not limited to:

1. On December 6, 2011 at 1:37 p.m., the facility was not maintaining a staff roster for attendance at fire drills to ensure all staff attended two drills per year.

2. On December 6, 2011 at 1:37 p.m., the fire drill forms did not contain the required minimum information including location of the "fire", specific type of "fire" simulated, time to complete the simulated evacuation of all patients in the smoke compartment, and the facility was using "Dr. Red" for fire during drills and not the standardized "Code Red".

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

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 19/18.3.4, 9.6).
Findings include, but are not limited to:

1. On December 6, 2011 at 5:07 p.m., the fire alarm pull station at 6 main by the west stair and in the kitchen that were installed at 58 1/2" above the floor which exceeded the 54" requirement in NFPA 72, and was not installed 42-48" above the floor to the handle.

2. On December 7, 2011 at 9:42 a.m., there was no smoke detection at the skylight area of the main lobby.

3. On December 7, 2011 at 10:48 a.m., there were non listed or approved metal cage covers installed over the fire alarm pull stations in the lobby of 1 east and in the Johnson Unit and at the Chapel entrance.

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

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). include, but are not limited to:

1. On December 6, 2011 at 3:21 p.m., the facility failed to conduct and document the annual fire alarm inspection for building 5809 which includes 65, L&D, and Johnson Unit. The last inspection was 4/15/2009 and was past due since 4/15/2010.

2. On December 6, 2011 at 3:21 p.m., the facility had no documentation of technician competence for the staff responsible for inspecting, testing, and maintaining the fire alarm system.

3. On December 7, 2011 at 10:27 a.m., the fire alarm pull station in the dining room was obstructed with a large upholstered chair.

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

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 19/18.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:

1. On December 6, 2011 at 4:55 p.m., there were vacant patient rooms on several floors of the facility that were used as storage without verification of ordinary hazard sprinkler protection for the rooms. These were found on 6 main, 5 main, and other areas of the building.

2. On December 6, 2011 at 4:55 p.m., there were painted sprinkler heads in 658, therapy by 659, in 661, in patient and family library on 6.

3. On December 6, 2011 at 5:05 p.m., there were no sprinklers installed in the closet at 6 main by the west stair. There were no sprinklers installed in the electrical closet of East of the Inpatient Dialysis, and the 1st floor ED family waiting room electrical closet.

4. On December 7, 2011 at 8:11 a.m., there were no sprinkler heads installed underneath the ducts in the 41/51 penthouse that exceeded 48" in width creating an obstruction.

5. On December 7, 2011 at 8:45 a.m., there was a missing escutcheon plate in the bathroom of room 258 Outpatient Infusion.

6. On December 7, 2011 at 9:21 a.m., there were no sprinkler heads installed above the outside overhang east of the ED courtyard above the EMS sheds. There were no sprinklers installed above the storage box at the Johnson Unit Courtyard overhang.

7. On December 7, 2011 at 9:50 a.m., there were wooden grid ceilings exceeding 4' in width installed in the main lobby computer areas with 4 1/2"x 4 1/2" x 4 1/2" openings and 1/2" dividers that obstructed the sprinkler discharge pattern from reaching the floor and walls in accordance with 1999 NFPA 13 5-5.5.3.1, which states sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.

8. On December 7, 2011 at 10:14 a.m., there was a missing escutcheon plate at the cafeteria serving line and corroded sprinkler heads.

9. On December 7, 2011 at 10:37 a.m., there was inadequate sprinkler coverage for the combustible stairway in the auditorium leading up to the projection room from the ticket counter.

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined that the facility failed to ensure the 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). Findings include, but are not limited to:

1. On December 6, 2011 at 2:34 p.m., the facility had no documentation of ever conducting a forward flow test of the backflow prevention devices installed in the sprinkler system. NFPA 25 9-6.2.1

2. On December 6, 2011 at 2:34 p.m., the facility had no documentation of technician competence for the staff responsible for inspecting, testing, and maintaining the fire sprinkler system.

3. On December 6, 2011 at 2:34 p.m., the facility was not inspecting all electronic sprinkler tamper switches monthly in accordance with NFPA 25 9-3.3.1 ex. #1.

4. On December 6, 2011 at 2:45 p.m., the facility was not testing all water flow alarms quarterly in accordance with NFPA 25 9-2.7 including branch lines.

5. On December 6, 2011 at 5:26 p.m., there were painted sprinkler heads in the shower room across from 559 and in shower room by 311, in the IT rack room of 4 north, and 4 ancillary, and a textured sprinkler head in room 560 that had not been replaced.

6. On December 6, 2011 at 6:48 p.m., there were intermixed SR and QR sprinkler heads located in the SPR3 scrub room 4 Ancillary and a sprinkler head installed within 4" of the corner of the wall in the same location.

7. On December 7, 2011 at 9:29 a.m., there were missing ceiling tiles in the ED room 31 that could potentially delay the sprinkler activation.

8. On December 7, 2011 at 10:02 a.m., there were painted sprinkler heads at the South building west stair first floor.

9. On December 7, 2011 at 10:08 a.m., there were corroded sprinkler heads at the cart wash location in the kitchen, at the dish machine in the kitchen and throughout the kitchen area.

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

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 19/18.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:

1. On December 6, 2011 at 2:26 p.m., the facility did not retain the previous years fire extinguisher tags to provide verification of monthly inspections. Two extinguishers in the facility were found to have outdated tags affixed that were not initialed monthly, these were located in the cafe' and in the unoccupied portion of the facility.

2. On December 6, 2011 at 8:09 a.m., the fire extinguisher located in the NE penthouse and in the Respiratory Care hallway and at the food service loading dock were installed more than 60" above the finished floor to the top of the handle.

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

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 19/18.7.4). Findings include, but are not limited to:

1. On December 6, 2011 at 4:10 p.m., the smoking policy indicated that smoking materials were prohibited in private vehicles located on any property owned by the facility which was not being enforced. There were improperly discarded cigarettes located in the parking garage.

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

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 unexpected fire (LSC 19/18.5.2.1, 19/18.5.2.2, 9.2, NFPA 90A). Findings include, but are not limited to:

1. On December 7, 2011 at 11:12 a.m., there was a white plastic exhaust duct installed at the laundry dryer in the Johnson unit that was crushed, and was not listed for the application.

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined 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 and no projections exceeding 4 1/2" below 40" from the floor. 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 December 6, 2011 at 6:00 p.m., there was an unattended blood pressure machine in the corridor at 581 and a linen cart at 586 creating obstructions to the 8' corridor width. There was a tray cart in the corridor unattended at room 586, a bladder scanner and wheel chair at room 584 unattended.

2. On December 6, 2011 at 7:14 p.m., there was a computer on wheels (WOW) charging in the corridor at room 305.

3. On December 7, 2011 at 10:36 a.m., there were tables and carts stored in the exit passage from the auditorium creating an obstruction.

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

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, unless in limited quantities or flame retardant. This resulted in the potential for excessive fire spread (LSC 19/18.7.5.4). Findings include, but are not limited to:

1. On December 6, 2011 at 5:22 p.m., there was a spray foam based artificial tree in the 5th floor elevator lobby main and in the Johnson Unit lobby by the east entrance 1st floor.

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

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 (LSC 19/18.3.2.4, 4.3.1.1.2). Findings include, but are not limited to:

1. On December 6, 2011 at 6:06 p.m., there were oxygen cylinders stored in the clean supply room on 5 north, 3 south, and the Johnson Unit, and the electrical switches and outlets were installed within 60" of the floor.

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

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)
Findings include, but are not limited to:

1. On December 6, 2011 at 3:53 p.m., the facility had no documentation of the 3 year 4 hour load bank test at 80% load for the three diesel powered generators in accordance with 1999 NFPA 110 Figure A-6-3.1(a) #7 Prime Mover (h) (EPS at minimum of 80% nameplate rating every 3 years for 4 hours). The facility was only conducting 30% loads every 3 years for 4 hours based off the 2010 110 section 8.4.9.5.1, which has not been adopted by CMS for maintenance of EPS.

2. On December 6, 2011 at 3:21 p.m., the facility had no documentation of technician competence for the staff responsible for inspecting, testing, and maintaining the generators.

3. On December 6, 2011 at 3:53 p.m., the facility was not logging the electrolyte levels of the starting batteries weekly.

4. On December 7, 2011 at 7:15 a.m., the engine kill switches for the 3 generators were located within the room enclosing the generators.

5. On December 7, 2011 at 7:15 a.m., the facility was not documenting the time to pick up the building load during generator runs monthly. Two generators were found to exceed the maximum time of 10 seconds.

6. On December 7, 2011 at 7:15 a.m., the 51 generator day tank was vented inside the room and not 12' above grade at the exterior of the building. The 51 generator was also found to have a hole forming in the fuel line from rubbing on a bolt head, and there was a fuel leak on the fuel filter/ day tank side of the generator.

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.

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). Findings include, but are not limited to:

1. On December 6, 2011 at 5:00 p.m., there were sinks in bathrooms on 6 main without GFCI protection for the outlets. This was also found at the sink in the Rehab kitchen.

2. On December 6, 2011 at 5:15 p.m., there was a relocatable power tap in use at the phone system on 6 East ancillary store room, and at the 2nd floor IT rack room within Outpatient Infusion, in lieu of permanent wiring.

3. On December 6, 2011 at 5:45 p.m., there were non-patient area relocatable power strips in use in the Rehab Therapy Gym at the computer cart, in ultrasound, in Radiology waiting, in Respiratory Therapy 4 ancillary, in room 21, 20, ED nurse station, versus board at room 8, room 4 in ED. There was a permanently attached patient care area approved relocatable power strip in use at the patient schedule monitor and the cord end had been replaced. There were also non-patient area approved RPTs at the game system that were also daisy-chained. Relocatable power strips were located on the floor of the physician dictation office at the nurse station rehab alcove on 5 north.

4. On December 6, 2011 at 6:10 p.m., there were "household use" cooking appliances in the outpatient therapy gym breakroom and the inpatient therapy breakroom that were used on a more than limited personal use amount per interview of the Facilities Director, which is not consistent with the UL listing for the appliances. The appliances were also plugged into relocatable power strips and not directly into the wall outlets.

5. On December 6, 2011 at 7:02 p.m., there was a refrigerator plugged into a relocatable power strip in 3 South Social Workers office and appliances plugged into power strips in the ED Doctor Consult Room.

6. On December 7, 2011 at 8:25 a.m., there was a missing outlet cover at the Pharmacy fume hood 2 Ancillary.

7. On December 7, 2011 at 10:07 a.m., there were "way finding lights" installed in corridors on the 1st floor that were plugged into relocatable power taps above the ceiling grid system in lieu of permanent wiring and the lights were not UL listed.

8. On December 7, 2011 at 10:16 a.m., there were brown and green "zip cord" style extension cords in the cafeteria at the holiday lighting.

9. On December 7, 2011 at 10:40 a.m., there were long multi plug power strips in the projection room of the auditorium in lieu of installing additional outlets and permanent wiring.

10. On December 7, 2011 at 10:43 a.m., there was a microwave and refrigerator plugged into a RPT in the Psych Physician office and the RPT had exposed wires at the plug end.

11. On December 7, 2011 at 10:55 a.m., there was a floor outlet installed in the Johnson Unit at the couches that was missing a cover.

12. On December 7, 2011 at 10:56 a.m., there were daisy chained RPTs at the computer cart in the surveillance monitor area of the Johnson Unit.

13. On December 7, 2011 at 11:19 a.m., there were extension cords and relocatable power taps in use in the gift shop in lieu of permanent wiring and additional outlets.

14. On December 7, 2011 at 11:37 a.m., the ED Nurse Manager office had a refrigerator and coffee maker plugged into a relocatable power tap.

15. On December 7, 2011 at 11:39 a.m., there was a relocatable power tap permanently attached at the television in room 3, 2, and 1 in the Gamma Knife unit.

Surveyor was accompanied by the Director of Facilities who acknowledged the existence of these conditions.