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Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to maintain the integrity of smoke separations. This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 19/18.3.6.1, .2, .5). Findings include, but are not limited to:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., above the ceiling at the 2-hour separation outside of the Risk Management Office, there was a 1/2" penetration around pipe on both sides. There was also some household spray foam used in the same area.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the ceiling in the electrical (room 107/BM03) was incomplete.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator and Associate Administrator that the facility failed to maintain the integrity of smoke separations. This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 19/18.3.6.1, .2, .5). Findings include, but are not limited to:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were unsealed wall penetrations on the Mezzanine and above the switchboard in EM03.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were unsealed ceiling penetrations in the CT closet, & in the walls in 1230 server room.
Surveyor was accompanied by the Quality Coordinator and Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to maintain exit corridor doors resist the passage of smoke into the means of egress in the event of a hostile fire event (LSC 18.2.3.5, Table 19/18.3.2.1, 19/18.3.6.3, Exception 2; A19/18.3.6.3.3). Findings include, but are not limited to:

1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the fire doors at the red elevator lobby, South side, did not latch when tested.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the 90-minute cross corridor doors by 233 did not latch when tested.
3. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were roller latches installed on the cross corridor doors near the conference room #4.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator and Associate Administrator that the facility failed to install vision panels in exit corridor walls and/or doors. This resulted in the potential for injury to staff and patients during an emergency. (LSC NFPA 101, 2000 Edition 18/19.3.6.5, 18.3.6.1, 19.3.6.2.3, 19.3.6.3.8). Findings include, but are not limited to:

1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the cross-corridor doors at the lobby on the first floor were missing vision panels.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the doors to the lobby on the 2nd floor near Family Birthing Center were missing vision panels in corridor 2C12.
3. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the cross corridor doors at 231 (2317) were missing vision panels.
Surveyor was accompanied by the Quality Coordinator and Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator and Associate Administrator that the facility failed to install vertical openings that are capable of resisting the passage of fire and provide basic smoke compartmentation. This resulted in the potential for the spread of fire and smoke vertically in multi-story facilities 1 hour rating up to 3 stories, 2 hour exceeding 3 stories. (LSC 19/18.3.1.1, 8.2.5.1). Findings include, but are not limited to:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the blue elevator door on the 1st floor did not latch when tested.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to install proper hold-open devices that will release on the actuation of the fire alarm or fire sprinkler system. This resulted in the potential for smoke and fire to spread to other areas of the facility (LSC 19/18.2.2.3). Findings include, but are not limited to:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., room 212 had been turned into a storage room and there was no door closer installed.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the fire door to the mezzanine in BM05 was tied open and the identification plate on the door had been painted over.
3. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no synchronized hardware on the cross-corridor door by the sleep lab and the doors going into the lobby.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator and Associate Administrator that the facility failed to maintain exit illumination on emergency power for a minimum of 90 minutes annually. 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. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the task illumination lights at the transfer switch were not hard-wired.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no task illumination at the transfer switch in BM14.
Surveyors were accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to maintain emergency preparedness plan current & readily available to all staff, affecting the entire building. 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. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the fire watch policy did not list the State Fire Marshal's Office or the local fire department to call. It says contact AHJ.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to provide required documentation of fire drills affecting 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. During the facility's record review on 10/22/2012 from 10:30 a.m. to 3:00 p.m., there was required information that was missing from the fire drill reports. Some examples are: number of patients evacuated (simulated); length of time to complete fire drill; no signature; no issues noted; no type of incident noted; no comments noted; & noting false alarms as fire drills (2/10/11).

Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator 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 18.3.4, 9.6). Findings include, but are not limited to:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no strobe in the Hospitalist Office; room 218; and no strobe in the bathroom.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no notification device in the staff sleep room #254.
3. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was a strobe in the patient restroom #258; in #243 treatment room 5; in #242 treatment room 6; in #241 treatment room #7.
4. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was a strobe in treatment room #8 door #236, treatment room #10 door #233, in Triage #1, OBS treatment 2 #262, restroom 264 in ER, in OBS treatment room 1 #263, in X-ray #1 restroom, in dressing room 1 near CT Scan, in CT room, in dressing room 219 near X-ray, in restroom 212 near CT, in MR dressing room 1 & 2, MRI restroom, in Bone Density room, in mammogram room, in dressing room 1 & 2 in mammogram & density, in room 330 in mammogram, in #327 outside mammogram, in ultrasound #2 and restroom, ultrasound #1 and restroom, in nuclear med, treatment 1 #1133 Cardio, in restroom 30, in treatment #3 Cardio, in Endoscopy #1 & #2, in restroom 1336 in Infusion, in minor procedure room 1, in restroom 1326, in 1371 in Infusion & Infusion restroom, in restroom 1357, in test/exam room in Infusion, in blood draw 1 & 2, in restroom 2336 in FBC near manager's office, in lactation room & restroom 2304, & in nursery 235.
5. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no fire alarm pull station at the PACU nurse station.
6. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no fire alarm pull station at the nurse station in the Family Birthing Center.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with Quality Coordinator & Associate Administrator 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). Findings include, but are not limited to:

1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the fire alarm pull station for the kitchen hood suppression was installed more than 54" from the floor.

2. During the facility record review on 10/22/2012 from 10:30 a.m. to 3:00 p.m., there was no documentation that staff had competency training on weekly, monthly, quarterly maintenance and testing of the fire alarm system.

3. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the pull station at the front entrance was blocked by a large potted plant.

Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13. This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 18.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was an on/off switch on the air compressor in the OBS treatment 2.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to ensure the sprinkler system is continuously maintained & in reliable operating condition for the entire building. This resulted in the potential for limited effectiveness of fire department operations 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. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the fire department connection outside the CUP did not indicate what building/area it supports. And also, the two FDCs on the main hospital building.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator that the facility failed to ensure the sprinkler system is continuously maintained & in reliable operating condition for the entire building. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:

2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no spare sprinkler head box at the Riser in the Chiller Room.

3. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the sprinkler head over the washer in the laundry was corroded.

4. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the sprinkler heads were being blocked by shower curtains in Physical Therapy (room 211); room 213; room 214; room 215; & room 216.

5. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no label on the housekeeping door #245 identifying that it is the main sprinkler riser location.

6. During the facility record review on 10/22/2012 from 10:30 a.m. to 3:00 p.m., there was no documention that staff had competency training on weekly, monthly, quarterly maintenance and testing of the sprinkler system.

7. During the facility record review on 10/22/2012 from 10:30 a.m. to 3:00 p.m., there was no documentation of a forward flow test of the backflow preventer device, including a graph of pressure and gallons per minute for the system demand and available water.

8. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no label on the OBS treatment #2 identifying that it is the dry system sprinkler riser location.

9. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., shower curtains in the Family Birthing Center were blocking the sprinkler heads. Examples are: rooms 2345, 2343, 2341, 2319, 2321 & 2323.

10. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was a corroded sprinkler head in room BM23 behind the telephone room.

11. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was storage within 18" of the sprinkler in the auditing records room (B415).

12. During the facility record review on 10/22/2012 from 10:30 a.m. to 3:00 p.m., there was no documentation of weekly, monthly maintenance and testing of the sprinkler system.

Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator that the facility failed to ensure safe smoking practices 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. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were cigarette butts in the bark dust in the front portion of the facility.
Surveyor was accompanied by the Quality Coordinator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator 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. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no chiller alarm outside either of the doors that can access the chiller room.

Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview it was determined it was determined, through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to install an approved ventilation hood and duct system. This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 4.6.12.1, 9.2.3, 19/18.3.2.6, NFPA 96 A.1.1.4, UL300). Findings include, but are not limited to:

1. On 10/22/2010 at 4:35 p.m., there were no hinges on the rooftop exhaust for the kitchen hood and the platform was only approximately 6" to 8".

Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to prohibit the use of portable space heating devices. This resulted in the potential for ignition of nearby combustibles (LSC 19/18.7.8). Findings include, but are not limited to:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was an oil-filled space heater in the ICU nurse station; a space heater under the desk in Materials Management without maintaining 3 foot clearance; a space heater in Purchasing Office without maintaining 3 foot clearance; an oil-filled heater in office room 114; an oil-filled space heater in room 102 (Plant OPS Coordinator); a space heater at the ER nurse station, oil-heater in CT control, oil-filled heater in Radiologist's office, oil-filled heater next to leather chair in Lab breakroom #114, in the Lab Director's office, in the Lab Manager's office, in Assistant Manager's office in Same Day Surgery, in Bio-medical Engineering room, .

Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator and Associate Administrator 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. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the corridor across from the sprinkler room 1393 was obstructed with a bench, trash, & carts minimizing the corridor width to less than 8 feet.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was equipment stored in the alcove that protruded more than 4" into the corridor.
Surveyor was accompanied by the Quality Coordinator and Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to ensure that no storage of highly flammable character existed in the corridors. This resulted in the potential for excessive fire spread (LSC 19/18.7.5.5, Exhibit 19/18.23). Findings include, but are not limited to:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was a document shredder that exceeded 32 gallons open to the corridor in 1233.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with the Quality Coordinator and Associate Administrator that the facility failed to provide safe storage for compressed gas. This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks (LSC 19/18.3.2.4, 4.3.1.1.2). Findings include, but are not limited to:

1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were outlets installed less than 60" from the floor in med gas room 1124 and in O2 storage in supply #1132.
Surveyor was accompanied by the Quality Coordinator and Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to ensure that piped in medical gas systems comply with NFPA 99. This resulted in the potential for injury to patients during medical procedures. Findings include but are not limited to:

1. On 10/22/2012 at 3:47 p.m., there was no curb containment on the delivery parking pad for accidental spills at the liquid oxygen tank.

Surveyor was accompanied by Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1. This resulted in the potential for injury to patients during medical procedures. Findings include:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were no records of the humidity level readings for the ORs. Interview indicated that the sensors had been ordered and received, but not installed as of this survey.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview it was determined, through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to maintain storage in an approved manner. This resulted in the potential for excessive fuel load and fire spread. Findings include, but are not limited to:

1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was combustible storage in the stairwell to the roof (5 large boxes).
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview it was determined, through on-going dialog with the Quality Coordinator that the facility failed to maintain storage in an approved manner. This resulted in the potential for excessive fuel load and fire spread. Findings include, but are not limited to:

1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., facility was not maintaining 24" from the ceiling in the storage room and the South end storage closet. Facility is non-sprinklered.
Surveyor was accompanied by the Quality Coordinator who acknowledged the existence of these conditions.

Based on observations and interview it was determined that the facility failed to store flammable and combustible liquids in an approved manner. This resulted in the potential for involving excessive amounts of flammable & combustible liquids during fire emergencies. Findings include, but not limited to:

1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were flammable & combustible liquids in the air handler room (BM20) that were not being stored in an approved cabinet.

2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was flammable & combustible materials being stored in the basement by the purple elevator open to the corridor.

Surveyor was accompanied by the Quality Coordinator and Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interviews it was determined through on-going dialog with Quality Coordinator & Associate Administrator that the facility failed to properly maintain the generator. This resulted in the potential for injury to staff during emergency conditions. (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2) Findings include, but are not limited to:

1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., staff were unable to identify the kill switch for the generator, which should be located outside the generator room, to shut the generator off in an emergency.

Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to ensure that 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. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was a relocatable power tap located in the CUP that was hanging from the cord rather than temporarily mounted.

2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were two relocatable power taps (RPTs) on the floor in the Pharmacy; on the floor of the House Supervisor's office (room 218); on the floor at ICU 2nd desk area across from room 220; in Materials Management; two RPTs on the floor in room 114; a RPT on the floor in purchasing office; RPT on the floor in the Plant OPS office; RPT in room 102 (Plant OPS Coordinator; RPT on the floor in room 103 (next to Plant OPS office); an RPT on the floor in room 244; & in office 2130.

3. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was an open junction box in the loading bay, in B410 telephone room, & in Plants OPS next to telephone room B406.

4. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were two transformers in the closet of room 1230 that were discolored from overheating.

Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator that the facility failed to ensure that 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. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was a for house-hold use only microwave in the staff breakroom.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were piggy-backed relocatable power taps on the floor of the manager's office.
3. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was a relocatable power tap on the floor in the back front office.
Surveyor was accompanied by the Quality Coordinator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to maintain the integrity of smoke separations. This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 19/18.3.6.1, .2, .5). Findings include, but are not limited to:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., above the ceiling at the 2-hour separation outside of the Risk Management Office, there was a 1/2" penetration around pipe on both sides. There was also some household spray foam used in the same area.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the ceiling in the electrical (room 107/BM03) was incomplete.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator and Associate Administrator that the facility failed to maintain the integrity of smoke separations. This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 19/18.3.6.1, .2, .5). Findings include, but are not limited to:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were unsealed wall penetrations on the Mezzanine and above the switchboard in EM03.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were unsealed ceiling penetrations in the CT closet, & in the walls in 1230 server room.
Surveyor was accompanied by the Quality Coordinator and Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to maintain exit corridor doors resist the passage of smoke into the means of egress in the event of a hostile fire event (LSC 18.2.3.5, Table 19/18.3.2.1, 19/18.3.6.3, Exception 2; A19/18.3.6.3.3). Findings include, but are not limited to:

1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the fire doors at the red elevator lobby, South side, did not latch when tested.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the 90-minute cross corridor doors by 233 did not latch when tested.
3. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were roller latches installed on the cross corridor doors near the conference room #4.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator and Associate Administrator that the facility failed to install vision panels in exit corridor walls and/or doors. This resulted in the potential for injury to staff and patients during an emergency. (LSC NFPA 101, 2000 Edition 18/19.3.6.5, 18.3.6.1, 19.3.6.2.3, 19.3.6.3.8). Findings include, but are not limited to:

1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the cross-corridor doors at the lobby on the first floor were missing vision panels.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the doors to the lobby on the 2nd floor near Family Birthing Center were missing vision panels in corridor 2C12.
3. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the cross corridor doors at 231 (2317) were missing vision panels.
Surveyor was accompanied by the Quality Coordinator and Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator and Associate Administrator that the facility failed to install vertical openings that are capable of resisting the passage of fire and provide basic smoke compartmentation. This resulted in the potential for the spread of fire and smoke vertically in multi-story facilities 1 hour rating up to 3 stories, 2 hour exceeding 3 stories. (LSC 19/18.3.1.1, 8.2.5.1). Findings include, but are not limited to:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the blue elevator door on the 1st floor did not latch when tested.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to install proper hold-open devices that will release on the actuation of the fire alarm or fire sprinkler system. This resulted in the potential for smoke and fire to spread to other areas of the facility (LSC 19/18.2.2.3). Findings include, but are not limited to:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., room 212 had been turned into a storage room and there was no door closer installed.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the fire door to the mezzanine in BM05 was tied open and the identification plate on the door had been painted over.
3. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no synchronized hardware on the cross-corridor door by the sleep lab and the doors going into the lobby.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator and Associate Administrator that the facility failed to maintain exit illumination on emergency power for a minimum of 90 minutes annually. 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. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the task illumination lights at the transfer switch were not hard-wired.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no task illumination at the transfer switch in BM14.
Surveyors were accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to maintain emergency preparedness plan current & readily available to all staff, affecting the entire building. 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. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the fire watch policy did not list the State Fire Marshal's Office or the local fire department to call. It says contact AHJ.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to provide required documentation of fire drills affecting 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. During the facility's record review on 10/22/2012 from 10:30 a.m. to 3:00 p.m., there was required information that was missing from the fire drill reports. Some examples are: number of patients evacuated (simulated); length of time to complete fire drill; no signature; no issues noted; no type of incident noted; no comments noted; & noting false alarms as fire drills (2/10/11).

Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator 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 18.3.4, 9.6). Findings include, but are not limited to:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no strobe in the Hospitalist Office; room 218; and no strobe in the bathroom.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no notification device in the staff sleep room #254.
3. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was a strobe in the patient restroom #258; in #243 treatment room 5; in #242 treatment room 6; in #241 treatment room #7.
4. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was a strobe in treatment room #8 door #236, treatment room #10 door #233, in Triage #1, OBS treatment 2 #262, restroom 264 in ER, in OBS treatment room 1 #263, in X-ray #1 restroom, in dressing room 1 near CT Scan, in CT room, in dressing room 219 near X-ray, in restroom 212 near CT, in MR dressing room 1 & 2, MRI restroom, in Bone Density room, in mammogram room, in dressing room 1 & 2 in mammogram & density, in room 330 in mammogram, in #327 outside mammogram, in ultrasound #2 and restroom, ultrasound #1 and restroom, in nuclear med, treatment 1 #1133 Cardio, in restroom 30, in treatment #3 Cardio, in Endoscopy #1 & #2, in restroom 1336 in Infusion, in minor procedure room 1, in restroom 1326, in 1371 in Infusion & Infusion restroom, in restroom 1357, in test/exam room in Infusion, in blood draw 1 & 2, in restroom 2336 in FBC near manager's office, in lactation room & restroom 2304, & in nursery 235.
5. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no fire alarm pull station at the PACU nurse station.
6. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no fire alarm pull station at the nurse station in the Family Birthing Center.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with Quality Coordinator & Associate Administrator 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). Findings include, but are not limited to:

1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the fire alarm pull station for the kitchen hood suppression was installed more than 54" from the floor.

2. During the facility record review on 10/22/2012 from 10:30 a.m. to 3:00 p.m., there was no documentation that staff had competency training on weekly, monthly, quarterly maintenance and testing of the fire alarm system.

3. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the pull station at the front entrance was blocked by a large potted plant.

Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13. This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 18.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was an on/off switch on the air compressor in the OBS treatment 2.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to ensure the sprinkler system is continuously maintained & in reliable operating condition for the entire building. This resulted in the potential for limited effectiveness of fire department operations 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. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the fire department connection outside the CUP did not indicate what building/area it supports. And also, the two FDCs on the main hospital building.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator that the facility failed to ensure the sprinkler system is continuously maintained & in reliable operating condition for the entire building. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:

2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no spare sprinkler head box at the Riser in the Chiller Room.

3. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the sprinkler head over the washer in the laundry was corroded.

4. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the sprinkler heads were being blocked by shower curtains in Physical Therapy (room 211); room 213; room 214; room 215; & room 216.

5. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no label on the housekeeping door #245 identifying that it is the main sprinkler riser location.

6. During the facility record review on 10/22/2012 from 10:30 a.m. to 3:00 p.m., there was no documention that staff had competency training on weekly, monthly, quarterly maintenance and testing of the sprinkler system.

7. During the facility record review on 10/22/2012 from 10:30 a.m. to 3:00 p.m., there was no documentation of a forward flow test of the backflow preventer device, including a graph of pressure and gallons per minute for the system demand and available water.

8. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no label on the OBS treatment #2 identifying that it is the dry system sprinkler riser location.

9. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., shower curtains in the Family Birthing Center were blocking the sprinkler heads. Examples are: rooms 2345, 2343, 2341, 2319, 2321 & 2323.

10. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was a corroded sprinkler head in room BM23 behind the telephone room.

11. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was storage within 18" of the sprinkler in the auditing records room (B415).

12. During the facility record review on 10/22/2012 from 10:30 a.m. to 3:00 p.m., there was no documentation of weekly, monthly maintenance and testing of the sprinkler system.

Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator that the facility failed to ensure safe smoking practices 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. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were cigarette butts in the bark dust in the front portion of the facility.
Surveyor was accompanied by the Quality Coordinator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator 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. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was no chiller alarm outside either of the doors that can access the chiller room.

Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview it was determined it was determined, through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to install an approved ventilation hood and duct system. This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 4.6.12.1, 9.2.3, 19/18.3.2.6, NFPA 96 A.1.1.4, UL300). Findings include, but are not limited to:

1. On 10/22/2010 at 4:35 p.m., there were no hinges on the rooftop exhaust for the kitchen hood and the platform was only approximately 6" to 8".

Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to prohibit the use of portable space heating devices. This resulted in the potential for ignition of nearby combustibles (LSC 19/18.7.8). Findings include, but are not limited to:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was an oil-filled space heater in the ICU nurse station; a space heater under the desk in Materials Management without maintaining 3 foot clearance; a space heater in Purchasing Office without maintaining 3 foot clearance; an oil-filled heater in office room 114; an oil-filled space heater in room 102 (Plant OPS Coordinator); a space heater at the ER nurse station, oil-heater in CT control, oil-filled heater in Radiologist's office, oil-filled heater next to leather chair in Lab breakroom #114, in the Lab Director's office, in the Lab Manager's office, in Assistant Manager's office in Same Day Surgery, in Bio-medical Engineering room, .

Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator and Associate Administrator 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. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., the corridor across from the sprinkler room 1393 was obstructed with a bench, trash, & carts minimizing the corridor width to less than 8 feet.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was equipment stored in the alcove that protruded more than 4" into the corridor.
Surveyor was accompanied by the Quality Coordinator and Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to ensure that no storage of highly flammable character existed in the corridors. This resulted in the potential for excessive fire spread (LSC 19/18.7.5.5, Exhibit 19/18.23). Findings include, but are not limited to:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was a document shredder that exceeded 32 gallons open to the corridor in 1233.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with the Quality Coordinator and Associate Administrator that the facility failed to provide safe storage for compressed gas. This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks (LSC 19/18.3.2.4, 4.3.1.1.2). Findings include, but are not limited to:

1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were outlets installed less than 60" from the floor in med gas room 1124 and in O2 storage in supply #1132.
Surveyor was accompanied by the Quality Coordinator and Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to ensure that piped in medical gas systems comply with NFPA 99. This resulted in the potential for injury to patients during medical procedures. Findings include but are not limited to:

1. On 10/22/2012 at 3:47 p.m., there was no curb containment on the delivery parking pad for accidental spills at the liquid oxygen tank.

Surveyor was accompanied by Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1. This resulted in the potential for injury to patients during medical procedures. Findings include:
1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were no records of the humidity level readings for the ORs. Interview indicated that the sensors had been ordered and received, but not installed as of this survey.
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview it was determined, through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to maintain storage in an approved manner. This resulted in the potential for excessive fuel load and fire spread. Findings include, but are not limited to:

1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was combustible storage in the stairwell to the roof (5 large boxes).
Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview it was determined, through on-going dialog with the Quality Coordinator that the facility failed to maintain storage in an approved manner. This resulted in the potential for excessive fuel load and fire spread. Findings include, but are not limited to:

1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., facility was not maintaining 24" from the ceiling in the storage room and the South end storage closet. Facility is non-sprinklered.
Surveyor was accompanied by the Quality Coordinator who acknowledged the existence of these conditions.

Based on observations and interview it was determined that the facility failed to store flammable and combustible liquids in an approved manner. This resulted in the potential for involving excessive amounts of flammable & combustible liquids during fire emergencies. Findings include, but not limited to:

1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were flammable & combustible liquids in the air handler room (BM20) that were not being stored in an approved cabinet.

2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was flammable & combustible materials being stored in the basement by the purple elevator open to the corridor.

Surveyor was accompanied by the Quality Coordinator and Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interviews it was determined through on-going dialog with Quality Coordinator & Associate Administrator that the facility failed to properly maintain the generator. This resulted in the potential for injury to staff during emergency conditions. (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2) Findings include, but are not limited to:

1. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., staff were unable to identify the kill switch for the generator, which should be located outside the generator room, to shut the generator off in an emergency.

Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator & Associate Administrator that the facility failed to ensure that 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. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was a relocatable power tap located in the CUP that was hanging from the cord rather than temporarily mounted.

2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were two relocatable power taps (RPTs) on the floor in the Pharmacy; on the floor of the House Supervisor's office (room 218); on the floor at ICU 2nd desk area across from room 220; in Materials Management; two RPTs on the floor in room 114; a RPT on the floor in purchasing office; RPT on the floor in the Plant OPS office; RPT in room 102 (Plant OPS Coordinator; RPT on the floor in room 103 (next to Plant OPS office); an RPT on the floor in room 244; & in office 2130.

3. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was an open junction box in the loading bay, in B410 telephone room, & in Plants OPS next to telephone room B406.

4. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were two transformers in the closet of room 1230 that were discolored from overheating.

Surveyor was accompanied by the Quality Coordinator & Associate Administrator who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Quality Coordinator that the facility failed to ensure that 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. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was a for house-hold use only microwave in the staff breakroom.
2. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there were piggy-backed relocatable power taps on the floor of the manager's office.
3. During the facility tour on 10/22/2012 from 3:00 p.m. to 6:30 p.m., there was a relocatable power tap on the floor in the back front office.
Surveyor was accompanied by the Quality Coordinator who acknowledged the existence of these conditions.