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Based on observations and interviews it was determined that the facility failed to ensure that opening protectives were maintained as required by 2000 NFPA 101, 18.1.1.4.2. This resulted in the potential for fire to spread throughout the building. Findings include, but are not limited to:

1. On May 23, 2012 at 9:45 a.m., the door separating the Small Mechanical Room from the Lobby was not labeled as a rated door, did not have an automatic closure installed, and had a manual flush bolt instead of an automatic flush bolt.

2. On May 23, 2012 at 9:45 a.m., there were 3 openings in the conduit passing through the floor of the IT Room off of the Small Mechanical Room that were not sealed properly. The Facility Supervisor stated that the fire stop usually installed had been removed and not replaced.

3. On May 23, 2012 at 10:02 a.m., the top hinges of the rated doors separating the Medical Center from the Hospital were not securely attached to the frame on both leafs.

4. On May 23, 2012 at 10:05 a.m., an unsealed penetration was found in the rated separation between the Medical Center and the Hospital above the ceiling tiles where a fire alarm wire passed through. This area above the door was also not finished with drywall tape and mud.

5. On May 23, 2012 at 11:13 a.m., the door separating the corridor from the Ultra Sound Room did not have an automatic closure installed as part of the suite separation.

6. On May 23, 2012 at 11:16 a.m., a door prop was found at the door separating the corridor from the Pharmacy, and at the door to the Mixing Room in the Pharmacy.

7. On May 23, 2012 at 11:19 a.m., there was no annual inspection tag on the roll down fire door separating the Pharmacy from the corridor. There was also items on the counter obstructing the door from closing.

8. On May 23, 2012 at 1:54 p.m., a conduit penetrating the floor/ceiling separation between the Main Electrical Room and the Patient Floor was improperly sealed with a non-rated spray foam.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that smoke barriers were maintained as required by 2000 NFPA 101, 18.3.6.1. This resulted in the potential for smoke to spread to other smoke compartments. Findings include, but are not limited to:

1. On May 23, 2012 at 10:41 a.m., an unsealed wall penetration was found where electrical conduit was passed through above the cross corridor doors and ceiling tiles at Patient Room 26.

On May 23, 2012 at 10:41 a.m., the Facility Services Supervisor indicated he was unaware of the penetration.

2. On May 23, 2012 at 10:54 am, the X-Ray and CT Scan Rooms were open to the corridor at the Control Room.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on records review, observations and interviews it was determined that the facility failed to ensure that doors were maintained as required by 1999 NFPA 80, 15-2.1.1, 15-2.3.3, 15-2.4.2, 2000 NFPA 101, 4.6.12.4, affecting the entire facility. This resulted in the potential for fire and smoke to spread throughout the building during a fire event. Findings include, but are not limited to:

1. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the facility did not have access to the 1999 version of NFPA 80 for inspecting, testing, and maintaining smoke and fire doors in the building.

2. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the facility did not have documentation of performing door inspections or making repairs to doors.

During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the Facility Services Supervisor indicated that he did not document door inspections or repairs made on doors.

3. During a tour of the facility on May 23, 2012 from 9:52 a.m. to 1:55 p.m., door wedges were found in the Infusion Therapy area, Admitting Office, Eye Clinic, and Room 14.

4. On May 23, 2012 at 10:45 a.m., the door separating the Employee Break Room located across from Patient Room 20 from the corridor did not latch when closed.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that exits were signed as required by 2000 NFPA 101, 18.2.10.1. This resulted in the potential for occupants to be confused when trying to exit the building. Findings include, but are not limited to:

1. On May 23, 2012 at 10:18 am, the corridor by the staff elevator to the stairs was improperly marked as an exit.

On May 23, 2012 at 10:18 a.m., the Facility Services Supervisor indicated he was unaware of the requirement.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on records review and interviews it was determined that the facility failed to ensure that the disaster plan met the requirements of 2000 NFPA 101, 18.7.1.1, 1999 NFPA 99, 11-4.2. This resulted in the potential for inefficient relocation of patients during widespread emergencies affecting the entire facility. Findings include, but are not limited to:

1. On May 23, 2012 from 1:08 p.m. to 1:25 p.m., the facility disaster plan located at the Nurse Station was reviewed and found to have the following deficiencies:

The fire policy was dated 4/21/11 and was past due for annual review and did not direct staff to relocate patients to an unaffected smoke compartment, there was no map of the facility showing the main utility shut-offs, there was no agreement for transferring patients to an equivalent facility after 96-hours, there was no transportation agreement for transferring patients, there was no plan for responding to extreme weather situations, there was no staffing plan, there was no policy for conducting fire watch if the fire alarm or fire sprinkler system was out of service and there was no direction to contact the Office of State Fire Marshal Healthcare Unit if a fire, fire watch or evacuation occurred at the facility.

On May 23, 2012 from 1:08 p.m. to 1:25 p.m., the Safety Officer and Facility Services Supervisor stated the disaster plan did not contain these items.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on records review and interviews it was determined that the facility failed to ensure that fire drills were being conducted as required by 2000 NFPA 101, 18.7.1.2. This resulted in the potential for staff to be unprepared during an emergency. Findings include, but are not limited to:

1. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., a review of the facility's fire drill records indicated that the day and time that a drill was held did not vary for each shift. The duration of the drill was also not being documented.


Per interview with the Safety Officer on May 23, 2012 at 8:20 a.m., staff was not marking doors to indicate that a room had been evacuated, only shutting doors and turning off lights. She also indicated that staff was not simulating an evacuation of the entire smoke compartment affected during every drill, only sometimes.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that fire alarm notification devices were installed as required by 2000 NFPA 101, 9.6.3.7. This resulted in the potential for patients to be injured during an alarm activation. Findings include, but are not limited to:

1. During a tour of the facility on May 23, 2012 from 9:30 a.m. to 2:00 p.m., fire alarm notification devices were found in the following prohibited patient areas: Patient Bathroom of Lab, Patient Bathroom of Infusion Therapy, Patient Bathroom of X-Ray, Patient Bathroom next to Ultra Sound and OR 1 and 2.

2. On May 23, 2012 at 10:13 a.m., there was no smoke detection in the Admitting area.

3. On May 23, 2012 at 10:13 a.m., the Sleep Room in the Doctor's Lounge did not have both audible and visual fire alarm notification devices.

4. On May 23, 2012 at 10:37 a.m., there was not a visual fire alarm notification device in the Staff Bathroom in the Patient Hallway. This condition also existed in the Staff Breakroom across from Patient Room 20 and the MRI Control Room.

5. On May 23, 2012 at 1:55 p.m., a sign indicating "F.A.C.P." was not installed on the door leading to the room with the fire alarm control panel.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on records review and interviews it was determined that the facility failed to ensure that the fire alarm system was maintained as required by 1999 NFPA 72, 7-1.2.2, 7-3.2, 2000 NFPA 101, 4.6.12.4, affecting the entire facility. This resulted in the potential for the fire alarm system to be maintained incorrectly, possibly becoming unreliable during a fire emergency. Findings include, but are not limited to:

1. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., there was no documentation of technician competency for staff performing weekly and monthly maintenance on the fire alarm system.

During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the Facility Services Supervisor stated that he was trained on the weekly and monthly maintenance of the fire alarm system by the former Facility Services Supervisor, and not by a trained technician.

2. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the fire alarm test reports did not indicate an annual test and did not list all devices and batteries tested. It also indicated that the system had horn/strobes, which was incorrect.

During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the Facility Services Supervisor indicated that the fire alarm service company inspected the system on a semi-annual basis. He also indicated that the system has chime/strobes and backup batteries.

3. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the facility did not have a copy of the 1999 version of NFPA 72 available for review.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that fire sprinklers were installed as required by 1999 NFPA 13, 5-1.1, 5-6.5.3.1. This resulted in the potential for fire to spread beyond control. Findings include, but are not limited to:

1. On May 23, 2012 at 9:48 a.m., a ventilation duct measuring over 4-feet in width did not have a fire sprinkler head installed under it in the Mechanical Room Unit "HRU1".

On May 23, 2012 at 9:48 a.m., the Facility Services Supervisor indicated that he was unaware of the requirement for a fire sprinkler.

2. During a tour of the facility on May 23, 2012 from 9:30 a.m. to 2:00 p.m., the areas between the fire doors and the elevator doors on each floor were not covered by a fire sprinkler. This condition existed on both elevators.

3. On May 23, 2012 at 10:14 a.m., the walls separating the middle desk in Admitting blocked the spray pattern of the fire sprinklers.

On May 23, 2012 at 10:14 a.m., the Safety Officer indicated she was unaware of the blocked spray pattern of the fire sprinklers.

4. On May 23, 2012 at 1:32 p.m., the door to the Receiving area was not identified with a sign as containing the fire sprinkler control valve room.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on records review and interviews it was determined that the facility failed to ensure that the fire sprinkler system was maintained as required by 1998 NFPA 25, 1-4.2, 2000 NFPA 101, 4.6.12.4, affecting the entire facility. This resulted in the potential for the fire sprinkler system to be maintained incorrectly, possibly becoming unreliable during a fire emergency. Findings include, but are not limited to:

1. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., there was no documentation of technician competency for staff performing weekly, monthly and quarterly maintenance on the fire sprinkler system.

Per interview with the Facility Services Supervisor on May 23, 2012 at 8:15 a.m., he stated that he was trained on the weekly, monthly and quarterly maintenance of the fire sprinkler system by the former Facility Services Supervisor, and not by a trained technician.

2. During a review of records on May 23, 2012 from 8:00 am to 9:30 am, the facility did not have a copy of the 1998 version of NFPA 25 available for review.

During a review of records on May 23, 2012 from 8:00 am to 9:30 am, the Facility Services Supervisor stated that he did not have access to the 1998 version of NFPA 25 for maintaining the fire sprinkler system.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on records review and observations it was determined that the facility failed to maintain fire extinguishers as required by 1998 NFPA 10, 4-4.1, 2000 NFPA 101, 4.6.12.4, affecting the entire building. This resulted in the potential for fire extinguishers to be unavailable during an emergency. Findings include, but are not limited to:

1. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the facility did not have access to the 1998 version of NFPA 10 for maintaining fire extinguishers.

2. On May 23, 2012 at 1:51 p.m., a fire extinguisher in Materials Management had a service tag dated 2010 and was past due for annual service.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and records review it was determined that the facility failed to ensure that the smoking policy was being enforced as required by 2000 NFPA 101, 18.7.4, affecting the exterior of the main entrance. This resulted in the potential for a fire to start from improperly disposed smoking materials. Findings include, but are not limited to:

1. On May 23, 2012 at 9:52 a.m., multiple cigarette butts were found in the combustible landscaping and on the ground near the Main Entrance and Emergency Department doors. There was no receptacle available for discarding smoking materials. The facility had a no smoking policy for the campus.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on records review, observations and interviews it was determined that the facility failed to ensure that the kitchen hood exhaust and suppression system were maintained as required by 1998 NFPA 96, 7-1.2, 8-2, 8-3, affecting the one kitchen. This resulted in the potential for a grease fire to burn out of control. Findings include, but are not limited to:

1. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., documents indicated that the kitchen hood suppression system was inspected annually instead of semi-annually.

2. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., there was no documentation available indicating that the kitchen exhaust hood was cleaned semi-annually.

3. On May 23, 2012 at 1:45 p.m., the kitchen hood and exhaust duct had grease build up.

On May 23, 2012 at 1:45 p.m., the Facility Supervisor stated that he cleaned the kitchen hood periodically, but had not had a third-party service clean the hood and duct since he began working at the facility.

4. On May 23, 2012 at 1:40 p.m., an electric skillet and hot plate were not being used under a kitchen exhaust hood with a suppression system.

On May 23, 2012 at 1:40 p.m., the Dietary Manager indicated that the skillet and hot plate were used on the counter and not under the exhaust hood.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that space heaters were used in accordance with 2000 NFPA 101, 18.7.8. This resulted in the potential for ignition of nearby combustibles. Findings include, but are not limited to:

1. On May 23, 2012 at 10:45 a.m., a space heater that did not shut off when tipped over was found in the Nurse Manager's Office across from Patient Room 22.

On May 23, 2012 at 10:45 a.m., the Safety Officer stated she was unaware of the space heater in the Nurse manager's office.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that corridors were clear of obstructions as required by 2000 NFPA 101, 18.2.3.3. This resulted in the potential for exits to be obstructed. Findings include, but are not limited to:

1. On May 23, 2012 at 9:45 a.m., 3 sheets of plywood were being stored in the corridor between the Small Mechanical Room and the stairs which was open to the main lobby.

2. On May 23, 2012 at 10:34 a.m., 2 cabinets were stored in the corridor across from Patient Room 34 reducing the width to less then 8 feet.

On May 23, 2012 at 10:34 a.m., the Safety Officer stated that she was unaware that they were obstructing the corridor.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that compressed gas cylinders were secured as required by 1999 NFPA 99, 8-3.1.11. This resulted in the potential for the cylinders to tip over and result in an unintentional discharge of gas. Findings include, but are not limited to:

1. On May 23, 2012 at 1:36 p.m., the large compressed gas tanks in the Medical Gas Room were not secured with two chains to prevent them from tipping over.

On May 23, 2012 at 1:36 p.m., the Facility Services Supervisor indicated he was unaware that there were not two chains securing the tanks.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that medical gas valves were marked as required by 1999 NFPA 99, 4-3.5.4.2. This resulted in the potential for injury if gas was shut off to the wrong area. Findings include, but are not limited to:

1. During a tour of the facility on May 23, 2012 from 9:30 a.m. to 2:00 p.m., zone valves for medical gas were not labeled for each room served in the corridor near the Doctor's Lounge, OR area, and throughout the patient care areas.

On May 23, 2012 from 10:24 a.m., the Facility Services Supervisor indicated that the labels included room numbers from the architectural drawings and not how the rooms currently were identified.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on records review, observations and interviews it was determined that the facility failed to ensure that the emergency generator was maintained as required by 1999 NFPA 110, 5-3.1, 6-3.1, 6-3.6, 6-4.7, 2000 NFPA 101, 4.6.12.4, affecting the entire facility. This resulted in the potential for a problem with the emergency generator to be undetected. Findings include, but are not limited to:

1. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., there was no documentation of technician competence for staff performing weekly and monthly maintenance on the emergency generator.

On may 23, 2012 at 8:15 a.m., the Facility Supervisor indicated that he was trained by the previous Facility Services Supervisor to perform maintenance on the generator.

2. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the facility did not have access to the 1999 version of NFPA 110 to perform maintenance on the emergency generator. The facility did not have a record indicating that the electrolyte level of the batteries were being checked weekly, or that the specific gravity levels were being measured and recorded monthly. The facility did not have a record of an annual service of the emergency generator since it was installed in 2007. The facility did not have a record of a 4-hour load bank test being performed since the generator was installed in 2007.

On May 23, 2012 at 8:35 a.m. the Facility Supervisor indicated that he could not find a record of a 4-hour load bank test, and that one had not been performed since he began his job approximately 2 years ago.

3 On May 23, 2012 at 11:04 a.m., the emergency generator showed signs of wet-stacking when it was started, as black exhaust was produced for the first 5 seconds or so before clearing.

On May 23, 2012 at 11:04 a.m., the Facility Services Supervisor indicated that the generator was run for approximately 30 minutes a week.

4 On May 23, 2012 at 1:53 p.m., there was no emergency powered lighting available at the automatic transfer switch of the emergency generator.

On May 23, 2012 at 1:53 p.m., the Facility Services Supervisor stated he was not aware of any emergency lighting available in the electrical room where the transfer switch was located.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that electrical connections were installed as required by 1999 NFPA 70, 210.8(B)(5), 305, 422, and 517. This resulted in the potential for staff and patients to be injured. Findings include, but are not limited to:

1. During a tour of the facility from 9:30 a.m. to 2:00 p.m., relocatable power taps were being used in lieu of permanent wiring in the following locations: Big Mechanical Room, Patient Financial Counselor's Office, and the Consultation Room in the ED.

During a tour of the facility from 9:30 a.m. to 2:00 p.m., the Facility Supervisor indicated he was unaware of the facility not being able to use relocatable power taps in these areas.

2. On May 23, 2012 at 9:56 a.m., a UPS was plugged into a relocatable power tap in the Lab.

3. On May 23, 2012 at 9:56 a.m., the electrical outlets above the counter in the Lab were not mounted at least 3.15-inches (8-centimeters) above the surface.

On may 23, 2012 at 9:56 a.m., the Facility Supervisor measured the height of the outlets and indicated that they were 2-inches above the surface of the counter.

4. On May 23, 2012 at 10:00 a.m., a 3-to-1 plug adapter was being used in lieu of permanent wiring in the Gift Shop at the computer.

5. On May 23, 2012 at 10:23 a.m., a non-GFCI outlet was within 6-feet of a sink in the Surgical Services Manager's Office.

6. During a tour of the facility from 9:30 a.m. to 2:00 p.m., household microwaves were in use in the following locations: Doctor's Lounge, Nourishment Room across from Patient Room 26, the Breakroom across from Patient Room 20, EMS Training Room and in the Cafe.

7. On May 23, 2012 at 10:32 a.m., a non-patient approved relocatable power tap was in use at Infusion Therapy, the L & D Nurse's Station and Mammography.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions..

Based on observations and interviews it was determined that the facility failed to ensure that alcohol-based hand rub dispensers were mounted away from electrical sources as required by S & C Letter 05-33, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623. This resulted in the potential for the liquid to ignite. Findings include, but are not limited to:

1. During a tour of the facility on May 23, 2012 from 9:30 a.m. to 2:00 p.m., alcohol-based hand rub dispensers were found mounted above the light switch in Patient Rooms 18, 20, 26, 30, 32 and 34. This condition also existed in Exam Room 3 of the ED.

During a tour of the facility on May 23, 2012 from 9:30 a.m. to 2:00 p.m., the Safety Officer indicated that she was unaware of the requirement.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that opening protectives were maintained as required by 2000 NFPA 101, 18.1.1.4.2. This resulted in the potential for fire to spread throughout the building. Findings include, but are not limited to:

1. On May 23, 2012 at 9:45 a.m., the door separating the Small Mechanical Room from the Lobby was not labeled as a rated door, did not have an automatic closure installed, and had a manual flush bolt instead of an automatic flush bolt.

2. On May 23, 2012 at 9:45 a.m., there were 3 openings in the conduit passing through the floor of the IT Room off of the Small Mechanical Room that were not sealed properly. The Facility Supervisor stated that the fire stop usually installed had been removed and not replaced.

3. On May 23, 2012 at 10:02 a.m., the top hinges of the rated doors separating the Medical Center from the Hospital were not securely attached to the frame on both leafs.

4. On May 23, 2012 at 10:05 a.m., an unsealed penetration was found in the rated separation between the Medical Center and the Hospital above the ceiling tiles where a fire alarm wire passed through. This area above the door was also not finished with drywall tape and mud.

5. On May 23, 2012 at 11:13 a.m., the door separating the corridor from the Ultra Sound Room did not have an automatic closure installed as part of the suite separation.

6. On May 23, 2012 at 11:16 a.m., a door prop was found at the door separating the corridor from the Pharmacy, and at the door to the Mixing Room in the Pharmacy.

7. On May 23, 2012 at 11:19 a.m., there was no annual inspection tag on the roll down fire door separating the Pharmacy from the corridor. There was also items on the counter obstructing the door from closing.

8. On May 23, 2012 at 1:54 p.m., a conduit penetrating the floor/ceiling separation between the Main Electrical Room and the Patient Floor was improperly sealed with a non-rated spray foam.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that smoke barriers were maintained as required by 2000 NFPA 101, 18.3.6.1. This resulted in the potential for smoke to spread to other smoke compartments. Findings include, but are not limited to:

1. On May 23, 2012 at 10:41 a.m., an unsealed wall penetration was found where electrical conduit was passed through above the cross corridor doors and ceiling tiles at Patient Room 26.

On May 23, 2012 at 10:41 a.m., the Facility Services Supervisor indicated he was unaware of the penetration.

2. On May 23, 2012 at 10:54 am, the X-Ray and CT Scan Rooms were open to the corridor at the Control Room.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on records review, observations and interviews it was determined that the facility failed to ensure that doors were maintained as required by 1999 NFPA 80, 15-2.1.1, 15-2.3.3, 15-2.4.2, 2000 NFPA 101, 4.6.12.4, affecting the entire facility. This resulted in the potential for fire and smoke to spread throughout the building during a fire event. Findings include, but are not limited to:

1. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the facility did not have access to the 1999 version of NFPA 80 for inspecting, testing, and maintaining smoke and fire doors in the building.

2. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the facility did not have documentation of performing door inspections or making repairs to doors.

During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the Facility Services Supervisor indicated that he did not document door inspections or repairs made on doors.

3. During a tour of the facility on May 23, 2012 from 9:52 a.m. to 1:55 p.m., door wedges were found in the Infusion Therapy area, Admitting Office, Eye Clinic, and Room 14.

4. On May 23, 2012 at 10:45 a.m., the door separating the Employee Break Room located across from Patient Room 20 from the corridor did not latch when closed.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that exits were signed as required by 2000 NFPA 101, 18.2.10.1. This resulted in the potential for occupants to be confused when trying to exit the building. Findings include, but are not limited to:

1. On May 23, 2012 at 10:18 am, the corridor by the staff elevator to the stairs was improperly marked as an exit.

On May 23, 2012 at 10:18 a.m., the Facility Services Supervisor indicated he was unaware of the requirement.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on records review and interviews it was determined that the facility failed to ensure that the disaster plan met the requirements of 2000 NFPA 101, 18.7.1.1, 1999 NFPA 99, 11-4.2. This resulted in the potential for inefficient relocation of patients during widespread emergencies affecting the entire facility. Findings include, but are not limited to:

1. On May 23, 2012 from 1:08 p.m. to 1:25 p.m., the facility disaster plan located at the Nurse Station was reviewed and found to have the following deficiencies:

The fire policy was dated 4/21/11 and was past due for annual review and did not direct staff to relocate patients to an unaffected smoke compartment, there was no map of the facility showing the main utility shut-offs, there was no agreement for transferring patients to an equivalent facility after 96-hours, there was no transportation agreement for transferring patients, there was no plan for responding to extreme weather situations, there was no staffing plan, there was no policy for conducting fire watch if the fire alarm or fire sprinkler system was out of service and there was no direction to contact the Office of State Fire Marshal Healthcare Unit if a fire, fire watch or evacuation occurred at the facility.

On May 23, 2012 from 1:08 p.m. to 1:25 p.m., the Safety Officer and Facility Services Supervisor stated the disaster plan did not contain these items.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on records review and interviews it was determined that the facility failed to ensure that fire drills were being conducted as required by 2000 NFPA 101, 18.7.1.2. This resulted in the potential for staff to be unprepared during an emergency. Findings include, but are not limited to:

1. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., a review of the facility's fire drill records indicated that the day and time that a drill was held did not vary for each shift. The duration of the drill was also not being documented.


Per interview with the Safety Officer on May 23, 2012 at 8:20 a.m., staff was not marking doors to indicate that a room had been evacuated, only shutting doors and turning off lights. She also indicated that staff was not simulating an evacuation of the entire smoke compartment affected during every drill, only sometimes.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that fire alarm notification devices were installed as required by 2000 NFPA 101, 9.6.3.7. This resulted in the potential for patients to be injured during an alarm activation. Findings include, but are not limited to:

1. During a tour of the facility on May 23, 2012 from 9:30 a.m. to 2:00 p.m., fire alarm notification devices were found in the following prohibited patient areas: Patient Bathroom of Lab, Patient Bathroom of Infusion Therapy, Patient Bathroom of X-Ray, Patient Bathroom next to Ultra Sound and OR 1 and 2.

2. On May 23, 2012 at 10:13 a.m., there was no smoke detection in the Admitting area.

3. On May 23, 2012 at 10:13 a.m., the Sleep Room in the Doctor's Lounge did not have both audible and visual fire alarm notification devices.

4. On May 23, 2012 at 10:37 a.m., there was not a visual fire alarm notification device in the Staff Bathroom in the Patient Hallway. This condition also existed in the Staff Breakroom across from Patient Room 20 and the MRI Control Room.

5. On May 23, 2012 at 1:55 p.m., a sign indicating "F.A.C.P." was not installed on the door leading to the room with the fire alarm control panel.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on records review and interviews it was determined that the facility failed to ensure that the fire alarm system was maintained as required by 1999 NFPA 72, 7-1.2.2, 7-3.2, 2000 NFPA 101, 4.6.12.4, affecting the entire facility. This resulted in the potential for the fire alarm system to be maintained incorrectly, possibly becoming unreliable during a fire emergency. Findings include, but are not limited to:

1. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., there was no documentation of technician competency for staff performing weekly and monthly maintenance on the fire alarm system.

During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the Facility Services Supervisor stated that he was trained on the weekly and monthly maintenance of the fire alarm system by the former Facility Services Supervisor, and not by a trained technician.

2. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the fire alarm test reports did not indicate an annual test and did not list all devices and batteries tested. It also indicated that the system had horn/strobes, which was incorrect.

During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the Facility Services Supervisor indicated that the fire alarm service company inspected the system on a semi-annual basis. He also indicated that the system has chime/strobes and backup batteries.

3. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the facility did not have a copy of the 1999 version of NFPA 72 available for review.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that fire sprinklers were installed as required by 1999 NFPA 13, 5-1.1, 5-6.5.3.1. This resulted in the potential for fire to spread beyond control. Findings include, but are not limited to:

1. On May 23, 2012 at 9:48 a.m., a ventilation duct measuring over 4-feet in width did not have a fire sprinkler head installed under it in the Mechanical Room Unit "HRU1".

On May 23, 2012 at 9:48 a.m., the Facility Services Supervisor indicated that he was unaware of the requirement for a fire sprinkler.

2. During a tour of the facility on May 23, 2012 from 9:30 a.m. to 2:00 p.m., the areas between the fire doors and the elevator doors on each floor were not covered by a fire sprinkler. This condition existed on both elevators.

3. On May 23, 2012 at 10:14 a.m., the walls separating the middle desk in Admitting blocked the spray pattern of the fire sprinklers.

On May 23, 2012 at 10:14 a.m., the Safety Officer indicated she was unaware of the blocked spray pattern of the fire sprinklers.

4. On May 23, 2012 at 1:32 p.m., the door to the Receiving area was not identified with a sign as containing the fire sprinkler control valve room.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on records review and interviews it was determined that the facility failed to ensure that the fire sprinkler system was maintained as required by 1998 NFPA 25, 1-4.2, 2000 NFPA 101, 4.6.12.4, affecting the entire facility. This resulted in the potential for the fire sprinkler system to be maintained incorrectly, possibly becoming unreliable during a fire emergency. Findings include, but are not limited to:

1. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., there was no documentation of technician competency for staff performing weekly, monthly and quarterly maintenance on the fire sprinkler system.

Per interview with the Facility Services Supervisor on May 23, 2012 at 8:15 a.m., he stated that he was trained on the weekly, monthly and quarterly maintenance of the fire sprinkler system by the former Facility Services Supervisor, and not by a trained technician.

2. During a review of records on May 23, 2012 from 8:00 am to 9:30 am, the facility did not have a copy of the 1998 version of NFPA 25 available for review.

During a review of records on May 23, 2012 from 8:00 am to 9:30 am, the Facility Services Supervisor stated that he did not have access to the 1998 version of NFPA 25 for maintaining the fire sprinkler system.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on records review and observations it was determined that the facility failed to maintain fire extinguishers as required by 1998 NFPA 10, 4-4.1, 2000 NFPA 101, 4.6.12.4, affecting the entire building. This resulted in the potential for fire extinguishers to be unavailable during an emergency. Findings include, but are not limited to:

1. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the facility did not have access to the 1998 version of NFPA 10 for maintaining fire extinguishers.

2. On May 23, 2012 at 1:51 p.m., a fire extinguisher in Materials Management had a service tag dated 2010 and was past due for annual service.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and records review it was determined that the facility failed to ensure that the smoking policy was being enforced as required by 2000 NFPA 101, 18.7.4, affecting the exterior of the main entrance. This resulted in the potential for a fire to start from improperly disposed smoking materials. Findings include, but are not limited to:

1. On May 23, 2012 at 9:52 a.m., multiple cigarette butts were found in the combustible landscaping and on the ground near the Main Entrance and Emergency Department doors. There was no receptacle available for discarding smoking materials. The facility had a no smoking policy for the campus.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on records review, observations and interviews it was determined that the facility failed to ensure that the kitchen hood exhaust and suppression system were maintained as required by 1998 NFPA 96, 7-1.2, 8-2, 8-3, affecting the one kitchen. This resulted in the potential for a grease fire to burn out of control. Findings include, but are not limited to:

1. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., documents indicated that the kitchen hood suppression system was inspected annually instead of semi-annually.

2. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., there was no documentation available indicating that the kitchen exhaust hood was cleaned semi-annually.

3. On May 23, 2012 at 1:45 p.m., the kitchen hood and exhaust duct had grease build up.

On May 23, 2012 at 1:45 p.m., the Facility Supervisor stated that he cleaned the kitchen hood periodically, but had not had a third-party service clean the hood and duct since he began working at the facility.

4. On May 23, 2012 at 1:40 p.m., an electric skillet and hot plate were not being used under a kitchen exhaust hood with a suppression system.

On May 23, 2012 at 1:40 p.m., the Dietary Manager indicated that the skillet and hot plate were used on the counter and not under the exhaust hood.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that space heaters were used in accordance with 2000 NFPA 101, 18.7.8. This resulted in the potential for ignition of nearby combustibles. Findings include, but are not limited to:

1. On May 23, 2012 at 10:45 a.m., a space heater that did not shut off when tipped over was found in the Nurse Manager's Office across from Patient Room 22.

On May 23, 2012 at 10:45 a.m., the Safety Officer stated she was unaware of the space heater in the Nurse manager's office.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that corridors were clear of obstructions as required by 2000 NFPA 101, 18.2.3.3. This resulted in the potential for exits to be obstructed. Findings include, but are not limited to:

1. On May 23, 2012 at 9:45 a.m., 3 sheets of plywood were being stored in the corridor between the Small Mechanical Room and the stairs which was open to the main lobby.

2. On May 23, 2012 at 10:34 a.m., 2 cabinets were stored in the corridor across from Patient Room 34 reducing the width to less then 8 feet.

On May 23, 2012 at 10:34 a.m., the Safety Officer stated that she was unaware that they were obstructing the corridor.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that compressed gas cylinders were secured as required by 1999 NFPA 99, 8-3.1.11. This resulted in the potential for the cylinders to tip over and result in an unintentional discharge of gas. Findings include, but are not limited to:

1. On May 23, 2012 at 1:36 p.m., the large compressed gas tanks in the Medical Gas Room were not secured with two chains to prevent them from tipping over.

On May 23, 2012 at 1:36 p.m., the Facility Services Supervisor indicated he was unaware that there were not two chains securing the tanks.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that medical gas valves were marked as required by 1999 NFPA 99, 4-3.5.4.2. This resulted in the potential for injury if gas was shut off to the wrong area. Findings include, but are not limited to:

1. During a tour of the facility on May 23, 2012 from 9:30 a.m. to 2:00 p.m., zone valves for medical gas were not labeled for each room served in the corridor near the Doctor's Lounge, OR area, and throughout the patient care areas.

On May 23, 2012 from 10:24 a.m., the Facility Services Supervisor indicated that the labels included room numbers from the architectural drawings and not how the rooms currently were identified.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on records review, observations and interviews it was determined that the facility failed to ensure that the emergency generator was maintained as required by 1999 NFPA 110, 5-3.1, 6-3.1, 6-3.6, 6-4.7, 2000 NFPA 101, 4.6.12.4, affecting the entire facility. This resulted in the potential for a problem with the emergency generator to be undetected. Findings include, but are not limited to:

1. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., there was no documentation of technician competence for staff performing weekly and monthly maintenance on the emergency generator.

On may 23, 2012 at 8:15 a.m., the Facility Supervisor indicated that he was trained by the previous Facility Services Supervisor to perform maintenance on the generator.

2. During a review of records on May 23, 2012 from 8:00 a.m. to 9:30 a.m., the facility did not have access to the 1999 version of NFPA 110 to perform maintenance on the emergency generator. The facility did not have a record indicating that the electrolyte level of the batteries were being checked weekly, or that the specific gravity levels were being measured and recorded monthly. The facility did not have a record of an annual service of the emergency generator since it was installed in 2007. The facility did not have a record of a 4-hour load bank test being performed since the generator was installed in 2007.

On May 23, 2012 at 8:35 a.m. the Facility Supervisor indicated that he could not find a record of a 4-hour load bank test, and that one had not been performed since he began his job approximately 2 years ago.

3 On May 23, 2012 at 11:04 a.m., the emergency generator showed signs of wet-stacking when it was started, as black exhaust was produced for the first 5 seconds or so before clearing.

On May 23, 2012 at 11:04 a.m., the Facility Services Supervisor indicated that the generator was run for approximately 30 minutes a week.

4 On May 23, 2012 at 1:53 p.m., there was no emergency powered lighting available at the automatic transfer switch of the emergency generator.

On May 23, 2012 at 1:53 p.m., the Facility Services Supervisor stated he was not aware of any emergency lighting available in the electrical room where the transfer switch was located.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that electrical connections were installed as required by 1999 NFPA 70, 210.8(B)(5), 305, 422, and 517. This resulted in the potential for staff and patients to be injured. Findings include, but are not limited to:

1. During a tour of the facility from 9:30 a.m. to 2:00 p.m., relocatable power taps were being used in lieu of permanent wiring in the following locations: Big Mechanical Room, Patient Financial Counselor's Office, and the Consultation Room in the ED.

During a tour of the facility from 9:30 a.m. to 2:00 p.m., the Facility Supervisor indicated he was unaware of the facility not being able to use relocatable power taps in these areas.

2. On May 23, 2012 at 9:56 a.m., a UPS was plugged into a relocatable power tap in the Lab.

3. On May 23, 2012 at 9:56 a.m., the electrical outlets above the counter in the Lab were not mounted at least 3.15-inches (8-centimeters) above the surface.

On may 23, 2012 at 9:56 a.m., the Facility Supervisor measured the height of the outlets and indicated that they were 2-inches above the surface of the counter.

4. On May 23, 2012 at 10:00 a.m., a 3-to-1 plug adapter was being used in lieu of permanent wiring in the Gift Shop at the computer.

5. On May 23, 2012 at 10:23 a.m., a non-GFCI outlet was within 6-feet of a sink in the Surgical Services Manager's Office.

6. During a tour of the facility from 9:30 a.m. to 2:00 p.m., household microwaves were in use in the following locations: Doctor's Lounge, Nourishment Room across from Patient Room 26, the Breakroom across from Patient Room 20, EMS Training Room and in the Cafe.

7. On May 23, 2012 at 10:32 a.m., a non-patient approved relocatable power tap was in use at Infusion Therapy, the L & D Nurse's Station and Mammography.

Surveyors were accompanied by the Facility Services Supervisor and Safety Officer who acknowledged the existence of these conditions..