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Building A4-South Campus-Cardiac Tower

Through observation during the survey, March 18 through March 26, 2014, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Director of Plant Operations;
1) Corridor doors contained gaps larger than on half inch (1/2") between the door stop and door.
a) Patient room #534
b) Patient room #549
Note: Corrected during survey
This deficiency effected 1 out of 8 smoke compartments
2) The mechanical room on the second (2nd) floor contains a double door in which one (1) leaf contained a manual flush bolt on the door. This door opens to the corridor and must be a positively latching door.
This deficiency effected 1 out of 8 smoke compartments
3) The third (3rd) floor ICU contains twelve (12) doors which have a bifold, breakaway type door which contains a roller latch at the breakaway portion and a manual flush bolt on the leaf which hold the door into the slide track. The swinging door does not contain a latching device to latch into the breakaway portion of the door on one side and a swinging door on the other side. The ICU area is sized at 14,795 square feet in size and is too large to be certified as a "Suite" of rooms. Therefore making this hallways in this area a corridor which dictates that doors opening into the corridor must positively latch.
Per 2000 Edition of NFPA 101, sections 19.3.6.1 and 19.2.5.7
This deficiency effected 1 out of 8 smoke compartments and 12 ICU patient rooms in that smoke compartment

Building AA-North Campus

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the doors to the corridor.

During the walk through of the facility, with the Director of Plant Operations:
1) Resident room #3002 would not latch which caused an inadequate fire/smoke seal.
Note: Corrected during survey
2) Resident room #3008 contained an excessive gap between the door frame and stop that exceeded 1/8 " in width which caused and inadequate smoke seal.
Note: Corrected during survey
3) The closet across from room #1010 contained a double door. The left leaf of the double door contained a slide lock type latch, this latch is not considered to be a positively latching device.
These deficiencies effected 2 out of 17 smoke compartments

Builidng A1-South Campus Towers A&B

Through observation during the survey, March 18 through March 26, 2014, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Director of Plant Operations;
1) Three (3) corridor doors would not latch into the frame when closed which prevented a positive smoke seal
a) The Spine Imaging Room contained a bed located in which it obstructed the door from being closed.
b) Patient room #418 would not latch into the frame
c) Patient room #530 would not latch into the frame
Note: Corrected during survey
This deficiency effected 3 out of 30 smoke compartments
2) Corridor doors contained gaps larger than on half inch (1/2") between the door stop and door.
a) Patient room #228
b) Patient room #452
c) Patient room #501
Note: Corrected during survey
This deficiency effected 3 out of 30 smoke compartments
3) Seven (7) closet doors, which opened directly to the corridor, contained manual flush operated bolts on the left leaf of the door opening, which failed to be a positively latching device.
a) Electrical closet outside room #448
b) Closet outside ICU room #12
c) Closet outside room #231
d) Closet outside room #LDR08
e) Closet outside room #LDR02
f) Communication closet outside room #214
g) IT closet outside room #IDF-B
This deficiency effected 6 out of 30 smoke compartments
4) Third (3rd) floor ICU "A" pod contains seventeen (17) doors which have a bifold, breakaway type door which contains a roller latch at the breakaway portion and a manual flush bolt on the leaf which hold the door into the slide track. The swinging door does not contain a latching device to latch into the breakaway portion of the door on one side and a swinging door on the other side. The ICU area is sized at 11,808 square feet in size and is too large to be certified as a "Suite" of rooms. Therefore making this hallways in this area a corridor which dictates that doors opening into the corridor must positively latch.
Per 2000 Edition of NFPA 101, sections 19.3.6.1 and 19.2.5.7
This deficiency effected 1 out of 30 smoke compartments and seventeed rresident rooms.

Building AA-North Campus

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the smoke barrier walls.

During the walk through of the facility, with the Director of Plant Operations, one (1) smoke wall, located at the first (1st) floor east wall, contained one (1) unsealed electrical conduit penetration without fire caulking or other approved method of maintaining the smoke rating of the wall.
Per 19.3.7.3 and 8.3.2.
Note: This deficiency was corrected during the survey
This deficiency effected 2 out of 17 smoke compartments

Building A1-South Campus Towers A&B

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the smoke barrier doors.

During the walk through of the facility, with the Director of Plant Operations, the smoke barrier doors at room #211 contained a gap larger than 1/8" between the doors when in the closed position.
Note: Corrected during survey
This deficiency effected 2 out of 30 smoke compartments

Building A1-South Campus-Towers A&B

Through observation testing during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the exits as readily accessible at all times.

During the walk through of the facility, with the Director of Plant Operations:
1) Two (2) sets of doors, located at the third (3rd) floor "Peds" entrance areas, contained magnetic lock down devices into the "Peds" area without delayed egress of access controlled doors. These doors are located in the path of egress, and a required path of egress to an exit, for other patients on the third (3rd) floor, therefore these doors cannot be locked into the "Peds" space without proper devices.
Per the 2000 Edition of NFPA 101, section 19.2.2.2.2
This deficiency effected 1 out of 30 smoke compartments and 2 required means of egress
2) The egress door, located at the Radiology waiting area, failed to contain an alarm on the delayed egress door.
Note: Corrected during survey
This defieincy effected 1 smoke compartment and 1 required means of egress
3) The first (1st) floor exit passageway at stair #3 contained a storage room which opens onto the passageway. Exit passageways cannot have any area which opens onto the passageway except normally occupied areas.
Per NFPA 101, section 7.1.3.2(9)(b)ii
This deficiency effected all 5 floors and 1 required means of egress from all floors

Building AI-Saddle Rock ED

Through observation testing during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the exits as readily accessible at all times.

During the walk through of the facility, with the Director of Plant Operations, the double egress doors located at the ambulance vestibule contained delayed egress magnetic holds with a keypad override system; however, the door did not have signage posted to indicate how the delayed function worked from the egress side of the door.
Per NFPA 101, section 7.2.1.6.1(d) states "On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS"
This deficiency effected 1 of 2 smoke compartments and 1 means of egress

Building AB-Centennial Medical Plaza

Through observation and testing during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the emergency lighting systems.

During the walk through of the facility, with the facility Maintenance Director, the battery-powered emergency light (frogeye light) located in the pharmacy, would not illuminate with the test button depressed.
Note: This deficiency was corrected during the survey.
This deficiency effected 1 of 3 smoke compartments

Building AH-Green Valley Ranch

Through observation and testing during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the emergency lighting systems.

During the walk through of the facility, with the Director of Plant Operations, the battery-powered emergency light (frogeye light) located outside of the ultrasound room , would not illuminate with the test button depressed.
This deficiency effected 1 of 2 means of egress paths.

Building A1-South Campus Towers A&B

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to install and maintain the fire alarm system.

During the walk through of the facility, with the Director of Plant Operations;
1) Areas which were open to the corridor failed to contain smoke detection as required.
a) Area outside of ICU room #17
b) Volunteer reception area on floor 3 (this area is not always staffed)
c) Nourishment room on floor 3
d) West wing Birth Center certificate area (this area is not always staffed)
Per NFPA 101, chapter 19, section 19.3.6.1 Exception No. 1
This deficiency effected 3 out of 30 smoke compartments
2) Twelve (12) operating rooms, located in the OR suite, failed to contain visual notification from the fire alarm system. The decibal readings were taken during a fire alarm and the readings indicated approximately four (4) decibals above ambient levels in the operating room.
Per NFPA 101, section 19.3.4.3.1, exception 1 and section 9.6.3
This deficiency effected 1 out of 30 smoke compartments and 12 operating rooms within that smoke compartment
3) The "physician sleeping room" in the cath lab area failed to contain visual notification in the sleeping area or the hallway to the sleeping area
Per NFPA 101, section 19.3.4.3.1
This deficiency effected 1 out of 30 smoke compartments

Building AC-Womens Imaging

Through a review of the records and discussions with staff during the survey, March 18 through March 26, 2014, it was determined that the facility failed to inspect and test the fire alarm per NFPA 72.

During the review of the facility records, with the Director of Plant Operations , documentation was not available to verify the annual testing of the fire alarm system for the 2013 calendar year.
Per NFPA 101 2000 Edition 19.3.4.5.1, 9.6.1, and NFPA 72 7-3 and 7-3.2.1.
This deficiency effected all smoke compartments

Building AH-Green Valley Ranch

Through a review of the records and discussions during the survey, conducted between March 19 and March 26, 2014, it was determined that the facility failed to inspect and test the fire alarm system.

During the review of the facility records, with the Director of Plant Operations, documentation was not available to verify theyearly testing of the fire alarm system including sensitivity testing of the smoke detectors every two (2) years.
Per NFPA 101, (Section 9.6, Paragraph 9.6.1.4), and NFPA 72, (Chapter 7, Paragraph 7-1.2.2).
This deficiency effected all smoke compartments

Building A1-South Campus-Towers A&B

Through observation and record review during the survey, March 18 through March 26, 2014, it was determined that the facility failed to continuously maintain the automatic fire sprinkler system.

During the walk through of the facility, with the Director of Plant Operations;
1) Testing documentation of the electric fire pump did not indicate that a transfer from normal power to emergency power occured during a full churn test. This fire pump contained an automatic transfer switch attached to the electric fire pump.
Per the 1998 Edition of NFPA 25, section 5-3.3.4
This deficiency effected all smoke comaprtments (30 out of 30)
2) Two sprinkler heads did not contain any pigment in the bulb which failed to indicate the temperature rating and classification of the sprinkler.
a) One (1) head located at the nurse station in the Radiology work room
b) One (1) head located in the Radiology lounge
Per NFPA 13, section 3-2.5.2
This deficiency effected 1 out of 30 smoke compartments

Building AA-North Campus

Through observation during the survey,March 18 through March 26, 2014, it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition.

During the walk through of the facility, with the Director of Plant Operations, one (1) sprinkler head, located in the 3rd floor elevator lobby, contained paint on the working parts of the sprinkler head.
This deficiency effected 1 out of 17 smoke compartments

Building AB-Centennial Medical Plaza

Through observation during the survey, March 18 through March 26, 2014, it was determined the facility failed to maintain the automatic sprinkler system per NFPA 25.

During the walk through of the facility, with the facility Maintenance Director, documentation was not available to verify a sprinkler gauge calibration or replacement occurred every five (5) years. Two (2) sprinkler gauges contained manufacturer dates of 2008.
Per NFPA 25. 1999 Edition of NFPA 25, section 2-3.2.
This deficiency effected all smoke compartments (4 of 4)

Building A1-South Campus Towers A&B

Through observation during the survey, March 18 through March 26, 2014, the fire suppression failed to provide complete protection for the cooking facilities per NFPA 96.

During the walk through of the facility, with the Director of Plant Operations;
1) The fire suppression nozzles for the double fryer area, did not provide full coverage of the area due to the nozzles being pointed away from the cooking area.
Per NFPA 96, Section 7-1.2 "Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment."
2) The deep fryer was sitting next to the range (with approximately a one inch (1 " ) gap between the two appliances) and did not contain splash protection between the stove and the deep fat fryer.
Per NFPA 96, Section 9-1.2.3 "All deep fat fryers shall be installed with at least a 16-in. (406.4-mm) space between the fryer and surface flames from adjacent cooking equipment.
Exception: Where a steel or tempered glass baffle plate is installed at a minimum 8 in. (203 mm) in height between the fryer and surface flames of the adjacent appliance."
Note: Both deficiencies were corrected during the survey
These deficiencies effected 1 out of 30 smoke compartments

Building A1-South Campus Towers A&B

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walkthrough of the facility, with the Director of Plant Operations, items were being stored in the third (3rd) floor corridors. The items listed below were observed to be in the corridor at 11:30 am on March 19, 2014 and again at 12:30pm on March 19, 2014. The items were in the exact locations at both times.
1) One (1) bp cuff cart outside of room #312
2) One (1) bp cuff cart outside room #319
c) One (1) wheeled computer cart outside room #317 (note-this item was plugged into the wall)
Per NFPA 101 2000 Edition, Chapter 7, section 7.1.10
Note: All items were moved during the survey
This deficiency effected 1 out of 30 smoke compartments

Building A1-South Campus Towers A&B

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the anesthetizing locations per NFPA 99.

During the walk through of the facility, with the Director of Plant Operations Director, humidity readings in the operating rooms were noted as being under twenty five percent (20%) on numerous occasions and different days. Records indicated that the average humidity reading in the operating rooms failed to be an average of 20% during the first 2 weeks of March 2014 and during the month of February 2014 readings range between 11% and 28% in February 2014.
Per CMS S&C letter 13-25-LSC dated April 19, 2013
This deficiency effected 1 out of 30 smoke compartments and all 12 operating rooms within the smoke compartment

Building A1-South Campus Towers A&B

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to install generator emergency stop switch as required.

During the walk through of the facility, with the Director of Plant Operations;
1) The three (3) generators failed to contain an emergency shut off switch for each generator located outside of the generator housing room or housing as required.
Per 1999 Edition of NFPA 110, section 3-5.5.2
2) The ATS switch room failed to contain a battery back up emergency light in the room.
Per the 1999 Edition of NFPA 110, section 5-3.1
This deficiency effected 1 of 30 smoke compartments

Building AB-Centennial Medical Plaza

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the generator emergency function.

During the walk through, with the facility Maintenance Director;
1) The diesel fueled emergency generator failed to have a remote alarm annunciator in a location readily observed by operating personnel.
Per 19.2.9.1, 7.9.2.3 and 2000 Edition of NFPA 110 section 3-5.6.1 "A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel."
2) The generator failed to contain an emergency shut off button located outside of the generator room.
Per the 1999 Edition of NFPA 110, section 3-5.5.2
This deficiency effected all smoke compartments (4 of 4)

Building AB-Centennial Medical Plaza

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to install and maintain electrical equipment in accordance with NFPA 70, National Electrical Code.

During the walkthrough of the facility, with the facility Maintenance Director, the Pharmacy contained 2 power-strips that were connected to each other (piggybacked) to gain electrical outlets.
This deficiency effected 1 of 4 smoke compartments

Building AH-Green Valley Ranch

Through observation and record review during the survey, March 18 through March 26, 2014, it was determined the facility failed to inspect, test and maintain the automatic sprinkler system per NFPA 25.

During the walk through of the facility, with the Director of Plant Operations, documentation was not available to indicate the quarterly testing of the sprinkler supervisory switches and flow alarms or the yearly testing of the sprinkler system.
Per 1999 Edition of NFPA 25, Chapter 2, section 2-3.3.
This deficiency effected all smoke compartments

Building A4-South Campus-Cardiac Tower

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly.

During the walkthrough of the facility, with the Director of Plant Operations, four (4) sets of ABHR's were installed within six (6') of each other on the third (3rd) floor ICU floor.
Note: Corrected during the survey
This deficiency effecetd 1 of 8 smoke compartments

Building A4-South Campus-Cardiac Tower

Through observation during the survey, March 18 through March 26, 2014, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Director of Plant Operations;
1) Corridor doors contained gaps larger than on half inch (1/2") between the door stop and door.
a) Patient room #534
b) Patient room #549
Note: Corrected during survey
This deficiency effected 1 out of 8 smoke compartments
2) The mechanical room on the second (2nd) floor contains a double door in which one (1) leaf contained a manual flush bolt on the door. This door opens to the corridor and must be a positively latching door.
This deficiency effected 1 out of 8 smoke compartments
3) The third (3rd) floor ICU contains twelve (12) doors which have a bifold, breakaway type door which contains a roller latch at the breakaway portion and a manual flush bolt on the leaf which hold the door into the slide track. The swinging door does not contain a latching device to latch into the breakaway portion of the door on one side and a swinging door on the other side. The ICU area is sized at 14,795 square feet in size and is too large to be certified as a "Suite" of rooms. Therefore making this hallways in this area a corridor which dictates that doors opening into the corridor must positively latch.
Per 2000 Edition of NFPA 101, sections 19.3.6.1 and 19.2.5.7
This deficiency effected 1 out of 8 smoke compartments and 12 ICU patient rooms in that smoke compartment

Building AA-North Campus

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the doors to the corridor.

During the walk through of the facility, with the Director of Plant Operations:
1) Resident room #3002 would not latch which caused an inadequate fire/smoke seal.
Note: Corrected during survey
2) Resident room #3008 contained an excessive gap between the door frame and stop that exceeded 1/8 " in width which caused and inadequate smoke seal.
Note: Corrected during survey
3) The closet across from room #1010 contained a double door. The left leaf of the double door contained a slide lock type latch, this latch is not considered to be a positively latching device.
These deficiencies effected 2 out of 17 smoke compartments

Builidng A1-South Campus Towers A&B

Through observation during the survey, March 18 through March 26, 2014, it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Director of Plant Operations;
1) Three (3) corridor doors would not latch into the frame when closed which prevented a positive smoke seal
a) The Spine Imaging Room contained a bed located in which it obstructed the door from being closed.
b) Patient room #418 would not latch into the frame
c) Patient room #530 would not latch into the frame
Note: Corrected during survey
This deficiency effected 3 out of 30 smoke compartments
2) Corridor doors contained gaps larger than on half inch (1/2") between the door stop and door.
a) Patient room #228
b) Patient room #452
c) Patient room #501
Note: Corrected during survey
This deficiency effected 3 out of 30 smoke compartments
3) Seven (7) closet doors, which opened directly to the corridor, contained manual flush operated bolts on the left leaf of the door opening, which failed to be a positively latching device.
a) Electrical closet outside room #448
b) Closet outside ICU room #12
c) Closet outside room #231
d) Closet outside room #LDR08
e) Closet outside room #LDR02
f) Communication closet outside room #214
g) IT closet outside room #IDF-B
This deficiency effected 6 out of 30 smoke compartments
4) Third (3rd) floor ICU "A" pod contains seventeen (17) doors which have a bifold, breakaway type door which contains a roller latch at the breakaway portion and a manual flush bolt on the leaf which hold the door into the slide track. The swinging door does not contain a latching device to latch into the breakaway portion of the door on one side and a swinging door on the other side. The ICU area is sized at 11,808 square feet in size and is too large to be certified as a "Suite" of rooms. Therefore making this hallways in this area a corridor which dictates that doors opening into the corridor must positively latch.
Per 2000 Edition of NFPA 101, sections 19.3.6.1 and 19.2.5.7
This deficiency effected 1 out of 30 smoke compartments and seventeed rresident rooms.

Building AA-North Campus

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the smoke barrier walls.

During the walk through of the facility, with the Director of Plant Operations, one (1) smoke wall, located at the first (1st) floor east wall, contained one (1) unsealed electrical conduit penetration without fire caulking or other approved method of maintaining the smoke rating of the wall.
Per 19.3.7.3 and 8.3.2.
Note: This deficiency was corrected during the survey
This deficiency effected 2 out of 17 smoke compartments

Building A1-South Campus Towers A&B

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the smoke barrier doors.

During the walk through of the facility, with the Director of Plant Operations, the smoke barrier doors at room #211 contained a gap larger than 1/8" between the doors when in the closed position.
Note: Corrected during survey
This deficiency effected 2 out of 30 smoke compartments

Building A1-South Campus-Towers A&B

Through observation testing during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the exits as readily accessible at all times.

During the walk through of the facility, with the Director of Plant Operations:
1) Two (2) sets of doors, located at the third (3rd) floor "Peds" entrance areas, contained magnetic lock down devices into the "Peds" area without delayed egress of access controlled doors. These doors are located in the path of egress, and a required path of egress to an exit, for other patients on the third (3rd) floor, therefore these doors cannot be locked into the "Peds" space without proper devices.
Per the 2000 Edition of NFPA 101, section 19.2.2.2.2
This deficiency effected 1 out of 30 smoke compartments and 2 required means of egress
2) The egress door, located at the Radiology waiting area, failed to contain an alarm on the delayed egress door.
Note: Corrected during survey
This defieincy effected 1 smoke compartment and 1 required means of egress
3) The first (1st) floor exit passageway at stair #3 contained a storage room which opens onto the passageway. Exit passageways cannot have any area which opens onto the passageway except normally occupied areas.
Per NFPA 101, section 7.1.3.2(9)(b)ii
This deficiency effected all 5 floors and 1 required means of egress from all floors

Building AI-Saddle Rock ED

Through observation testing during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the exits as readily accessible at all times.

During the walk through of the facility, with the Director of Plant Operations, the double egress doors located at the ambulance vestibule contained delayed egress magnetic holds with a keypad override system; however, the door did not have signage posted to indicate how the delayed function worked from the egress side of the door.
Per NFPA 101, section 7.2.1.6.1(d) states "On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS"
This deficiency effected 1 of 2 smoke compartments and 1 means of egress

Building AB-Centennial Medical Plaza

Through observation and testing during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the emergency lighting systems.

During the walk through of the facility, with the facility Maintenance Director, the battery-powered emergency light (frogeye light) located in the pharmacy, would not illuminate with the test button depressed.
Note: This deficiency was corrected during the survey.
This deficiency effected 1 of 3 smoke compartments

Building AH-Green Valley Ranch

Through observation and testing during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the emergency lighting systems.

During the walk through of the facility, with the Director of Plant Operations, the battery-powered emergency light (frogeye light) located outside of the ultrasound room , would not illuminate with the test button depressed.
This deficiency effected 1 of 2 means of egress paths.

Building A1-South Campus Towers A&B

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to install and maintain the fire alarm system.

During the walk through of the facility, with the Director of Plant Operations;
1) Areas which were open to the corridor failed to contain smoke detection as required.
a) Area outside of ICU room #17
b) Volunteer reception area on floor 3 (this area is not always staffed)
c) Nourishment room on floor 3
d) West wing Birth Center certificate area (this area is not always staffed)
Per NFPA 101, chapter 19, section 19.3.6.1 Exception No. 1
This deficiency effected 3 out of 30 smoke compartments
2) Twelve (12) operating rooms, located in the OR suite, failed to contain visual notification from the fire alarm system. The decibal readings were taken during a fire alarm and the readings indicated approximately four (4) decibals above ambient levels in the operating room.
Per NFPA 101, section 19.3.4.3.1, exception 1 and section 9.6.3
This deficiency effected 1 out of 30 smoke compartments and 12 operating rooms within that smoke compartment
3) The "physician sleeping room" in the cath lab area failed to contain visual notification in the sleeping area or the hallway to the sleeping area
Per NFPA 101, section 19.3.4.3.1
This deficiency effected 1 out of 30 smoke compartments

Building AC-Womens Imaging

Through a review of the records and discussions with staff during the survey, March 18 through March 26, 2014, it was determined that the facility failed to inspect and test the fire alarm per NFPA 72.

During the review of the facility records, with the Director of Plant Operations , documentation was not available to verify the annual testing of the fire alarm system for the 2013 calendar year.
Per NFPA 101 2000 Edition 19.3.4.5.1, 9.6.1, and NFPA 72 7-3 and 7-3.2.1.
This deficiency effected all smoke compartments

Building AH-Green Valley Ranch

Through a review of the records and discussions during the survey, conducted between March 19 and March 26, 2014, it was determined that the facility failed to inspect and test the fire alarm system.

During the review of the facility records, with the Director of Plant Operations, documentation was not available to verify theyearly testing of the fire alarm system including sensitivity testing of the smoke detectors every two (2) years.
Per NFPA 101, (Section 9.6, Paragraph 9.6.1.4), and NFPA 72, (Chapter 7, Paragraph 7-1.2.2).
This deficiency effected all smoke compartments

Building A1-South Campus-Towers A&B

Through observation and record review during the survey, March 18 through March 26, 2014, it was determined that the facility failed to continuously maintain the automatic fire sprinkler system.

During the walk through of the facility, with the Director of Plant Operations;
1) Testing documentation of the electric fire pump did not indicate that a transfer from normal power to emergency power occured during a full churn test. This fire pump contained an automatic transfer switch attached to the electric fire pump.
Per the 1998 Edition of NFPA 25, section 5-3.3.4
This deficiency effected all smoke comaprtments (30 out of 30)
2) Two sprinkler heads did not contain any pigment in the bulb which failed to indicate the temperature rating and classification of the sprinkler.
a) One (1) head located at the nurse station in the Radiology work room
b) One (1) head located in the Radiology lounge
Per NFPA 13, section 3-2.5.2
This deficiency effected 1 out of 30 smoke compartments

Building AA-North Campus

Through observation during the survey,March 18 through March 26, 2014, it was determined the facility failed to maintain the automatic sprinkler system in reliable operating condition.

During the walk through of the facility, with the Director of Plant Operations, one (1) sprinkler head, located in the 3rd floor elevator lobby, contained paint on the working parts of the sprinkler head.
This deficiency effected 1 out of 17 smoke compartments

Building AB-Centennial Medical Plaza

Through observation during the survey, March 18 through March 26, 2014, it was determined the facility failed to maintain the automatic sprinkler system per NFPA 25.

During the walk through of the facility, with the facility Maintenance Director, documentation was not available to verify a sprinkler gauge calibration or replacement occurred every five (5) years. Two (2) sprinkler gauges contained manufacturer dates of 2008.
Per NFPA 25. 1999 Edition of NFPA 25, section 2-3.2.
This deficiency effected all smoke compartments (4 of 4)

Building A1-South Campus Towers A&B

Through observation during the survey, March 18 through March 26, 2014, the fire suppression failed to provide complete protection for the cooking facilities per NFPA 96.

During the walk through of the facility, with the Director of Plant Operations;
1) The fire suppression nozzles for the double fryer area, did not provide full coverage of the area due to the nozzles being pointed away from the cooking area.
Per NFPA 96, Section 7-1.2 "Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment."
2) The deep fryer was sitting next to the range (with approximately a one inch (1 " ) gap between the two appliances) and did not contain splash protection between the stove and the deep fat fryer.
Per NFPA 96, Section 9-1.2.3 "All deep fat fryers shall be installed with at least a 16-in. (406.4-mm) space between the fryer and surface flames from adjacent cooking equipment.
Exception: Where a steel or tempered glass baffle plate is installed at a minimum 8 in. (203 mm) in height between the fryer and surface flames of the adjacent appliance."
Note: Both deficiencies were corrected during the survey
These deficiencies effected 1 out of 30 smoke compartments

Building A1-South Campus Towers A&B

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walkthrough of the facility, with the Director of Plant Operations, items were being stored in the third (3rd) floor corridors. The items listed below were observed to be in the corridor at 11:30 am on March 19, 2014 and again at 12:30pm on March 19, 2014. The items were in the exact locations at both times.
1) One (1) bp cuff cart outside of room #312
2) One (1) bp cuff cart outside room #319
c) One (1) wheeled computer cart outside room #317 (note-this item was plugged into the wall)
Per NFPA 101 2000 Edition, Chapter 7, section 7.1.10
Note: All items were moved during the survey
This deficiency effected 1 out of 30 smoke compartments

Building A1-South Campus Towers A&B

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the anesthetizing locations per NFPA 99.

During the walk through of the facility, with the Director of Plant Operations Director, humidity readings in the operating rooms were noted as being under twenty five percent (20%) on numerous occasions and different days. Records indicated that the average humidity reading in the operating rooms failed to be an average of 20% during the first 2 weeks of March 2014 and during the month of February 2014 readings range between 11% and 28% in February 2014.
Per CMS S&C letter 13-25-LSC dated April 19, 2013
This deficiency effected 1 out of 30 smoke compartments and all 12 operating rooms within the smoke compartment

Building A1-South Campus Towers A&B

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to install generator emergency stop switch as required.

During the walk through of the facility, with the Director of Plant Operations;
1) The three (3) generators failed to contain an emergency shut off switch for each generator located outside of the generator housing room or housing as required.
Per 1999 Edition of NFPA 110, section 3-5.5.2
2) The ATS switch room failed to contain a battery back up emergency light in the room.
Per the 1999 Edition of NFPA 110, section 5-3.1
This deficiency effected 1 of 30 smoke compartments

Building AB-Centennial Medical Plaza

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to maintain the generator emergency function.

During the walk through, with the facility Maintenance Director;
1) The diesel fueled emergency generator failed to have a remote alarm annunciator in a location readily observed by operating personnel.
Per 19.2.9.1, 7.9.2.3 and 2000 Edition of NFPA 110 section 3-5.6.1 "A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel."
2) The generator failed to contain an emergency shut off button located outside of the generator room.
Per the 1999 Edition of NFPA 110, section 3-5.5.2
This deficiency effected all smoke compartments (4 of 4)

Building AB-Centennial Medical Plaza

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to install and maintain electrical equipment in accordance with NFPA 70, National Electrical Code.

During the walkthrough of the facility, with the facility Maintenance Director, the Pharmacy contained 2 power-strips that were connected to each other (piggybacked) to gain electrical outlets.
This deficiency effected 1 of 4 smoke compartments

Building AH-Green Valley Ranch

Through observation and record review during the survey, March 18 through March 26, 2014, it was determined the facility failed to inspect, test and maintain the automatic sprinkler system per NFPA 25.

During the walk through of the facility, with the Director of Plant Operations, documentation was not available to indicate the quarterly testing of the sprinkler supervisory switches and flow alarms or the yearly testing of the sprinkler system.
Per 1999 Edition of NFPA 25, Chapter 2, section 2-3.3.
This deficiency effected all smoke compartments

Building A4-South Campus-Cardiac Tower

Through observation during the survey, March 18 through March 26, 2014, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly.

During the walkthrough of the facility, with the Director of Plant Operations, four (4) sets of ABHR's were installed within six (6') of each other on the third (3rd) floor ICU floor.
Note: Corrected during the survey
This deficiency effecetd 1 of 8 smoke compartments