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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 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 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 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.