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Based on observations and interview it was determined that the facility failed to maintain opening protection in the fire walls. This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 19.1.2.3, 19.1.1.4, 19.1.2.3). Surveyor was accompanied by the Director of Engineering and Maintenance staff
who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 9, 2012 at 5:27 pm, the cross-corridor fire doors marked 0019 did not latch when tested. This condition also existed at the Atrium.

Based on observations it was determined that the facility failed to maintain exit corridor doors to resist the passage of smoke in accordance with NFPA 80. This resulted in the potential for passage of smoke into the means of egress in the event of a hostile fire event (LSC 19.2.3.5, 19.3.6.3.1 Ex 2, 4.6.12.1, A19.3.6.3.3). Surveyor was accompanied by the Director of Engineering and Maintenance staff who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 10, 2012 at 8:20 am, a door prop was permanently installed on the closing side of the door separating the Conference Room from the Corridor.

Based on observations and interview it was determined that the facility failed to provide opening protection, which separates exit corridors from hazardous areas with a sprinkler and smoke partition in existing facilities (Ch. 19). This resulted in the potential for the spread of fire/smoke into other portions of the facility including the means of egress during a hostile fire event (LSC 19.3.2.6, 8.2.3.2, 7.2.1.8, 19.3.2.1). Surveyor was accompanied by the Director of Engineering and Maintenance staff who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 9, 2012 at 5:35 pm, 5 penetrations were found in the ceiling of the Stocking Room on the Lower Level, each measuring 1-2-inches in diameter.

2. On January 10, 2012 at 10:16 am, the door separating the Biohazard Door from the ED did not latch. This condition also existed at the Janitor's Closet from the corridor in Labor and Delivery, Dirty Utility Room on the Third Floor, and at Room 408 Storage on the Fourth Floor.

Based on observations and interview it was determined that the facility failed to install/ maintain exit access throughout the means of egress including the exterior to the public way or 50' from the building. (LSC 7.1, 7.2.1.5, 7.7, 19.2.1, 19.2.5.10). Surveyor was accompanied by the Director of Engineering and Maintenance staff who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 10, 2012 at 8:42 am, the West Stair exterior path of egress did not measure a minimum of 44-inches in width and was not an all-weather surface.

Based on observations and interview it was determined that the facility failed to provide adequate exit illumination to the public way with bulbs arranged so that if one bulb burned out there would still be adequate exit lighting. This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions (LSC 19.8.2.8). Surveyor was accompanied by the Director of Engineering and Maintenance staff who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 10, 2012 at 8:42 am, the West Stair exit path did not have exit lighting from the building to the public way that measured at least 1-foot candle and included at least two bulbs.

Based on observations, interviews and record review it was determined that the facility failed to maintain emergency action plan current & readily available. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1). Surveyor was accompanied by the Director of Engineering and Maintenance staff who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 9, 2012 at 4:00 pm, a review of the facility's disaster plan from the Switchboard in the Lobby revealed the following deficiencies: the plan was past due for an annual review and was last dated 2/2010; there was no current hazard-risk assessment included; the Code Red policy dated 12/9/10 was past due for review; the fire response portion of the disaster plan stated to "pull the pull station handle or call the operator by dialing 911"; RACE did not include the defend in place procedure of relocating to an adjacent smoke compartment. Staff were also required to wait for an order before evacuating the area. The plan did not include procedures for responding to volcanic or windstorm events. There was no written procedure on how to manually start the emergency generator if it failed to start automatically.

Based on observations and record reviews it was determined that the facility failed to provide fire drills for all staff. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2). Surveyor was accompanied by the Director of Engineering and Maintenance staff who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 10, 2012 at 3:50 pm, a review of the fire drill records for the facility indicated there was no documentation of the duration of the drills, number of people evacuated, the type of fire simulated, or the location in the building.

Based on record reviews and interviews it was determined that the facility failed to provide fire drills for all staff. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19.7.1, A.19.7.1). Surveyor was accompanied by the Director of Engineering and Maintenance staff
who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 9, 2012 at 1 pm, a review of the facility's fire drill records revealed the following deficiencies: the time of day was not recorded on drills conducted 8/18/11 (Surgery) and 8/30/11 (Same Day Care). There was no documentation of a drill being held on Swing Shift in the fourth quarter of 2011. Coded announcements were used to initiate drills outside the allowed time window of 9 pm to 6 am; on 1/3/11 at 3 pm, 1/11/11 at 2 pm and 3:35 pm, 1/21/11 at 6:12 pm, 5/30/11 at 3:30 pm, 11/30/11 at 3:45 pm, and 1/1/12 at 11:30 am. On 1/31/11, the fire drill form did not include documentation of staff attendance, the performance of life safety systems, comments on staff performance and which notification method was used during the drill.

2. On January 9, 2012 at 2:26 pm, a review of documentation on annual staff training indicated that 201 out of 750 staff members listed were past due for annual fire and life safety inservice training. Of the 201 past due, several were documented as last trained in 2005. Per interview with Human Resource staff, the current number of staff employed is 902, including 17 new hires.

Based on observations it was determined that the facility failed to install fire alarm system in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (1999 NFPA 72, 4-3.4, LSC 19.3.4, 9.6). Surveyor was accompanied by the Director of Engineering and Maintenance staff who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 10, 2012 at 9:38 am, there was no audible fire alarm notification appliance in the Doctor's Sleeping Room, and in the Hospitalist Room 327, that complied with NFPA 72.

Based on observations it was determined that the facility failed to install fire alarm system in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 38.3.4, 9.6, 1999 NFPA 72, 1-5.2.5.2). Surveyor was accompanied by the Vice President of Facilities and Director of Engineering who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 10, 2012 at 1:37 pm, the electrical circuit serving the fire alarm control panel was improperly labeled in the panel, and the breaker was painted red.

2. On January 10, 2012 at 1:57 pm, there was no fire alarm notification appliance installed in the West Physician's Room.

Based on observations it was determined that the facility failed to ensure that there was complete sprinkler coverage in accordance with NFPA 13 for all portions of the building. This resulted in the potential for sprinkler failure and for uncontrolled fire progression in the event of a fire (LSC 19.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Surveyor was accompanied by the Director of Engineering and Maintenance staff
who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 9, 2012 at 6:16 pm, a fire sprinkler head was installed within 4-inches to a wall in Room 140, and the Medical Staff Coordinator's Office.

2. On January 9, 2012 at 6:20 pm, the fire department connection signs did not indicate the areas of the building served.

3. On January 9, 2012 at 6:37 pm, there was no fire sprinkler protection under the canopy outside of the Kitchen where combustibles were stored.

4. On January 9, 2012 at 6:42 pm, the Tray Return area in the Cafeteria was not protected by a fire sprinkler.

5. On January 10, 2012 at 9:20 am, the ED Registration Area by the annunciator panel lacked proper fire sprinkler coverage.

6. On January 10, 2012 at 9:30 am, standard and quick response fire sprinkler heads were intermixed in the ED Office area.

Based on observations and record review it was determined that the facility failed to ensure the sprinkler system is continuously maintained & in reliable operating condition. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 (1999) 3-2.91, .2, .3, 10-2.6, NFPA 25 (1998) 1-4.2, 9.6.2.1, .2). Surveyor was accompanied by the Director of Engineering and Maintenance staff who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 9, 2012 at 2 pm, a review of the facility's fire sprinkler records indicated the Kitchen and Main Building forward flow test results did not include the demand of sprinkler system to demonstrate whether the system passed or failed.

2. During a tour of the facility on January 9, 2012 from 12:30 to 7 pm, and January 10, 2012 from 8:20 to 11:19 am, escutcheon rings were missing around fire sprinkler heads in the OR Recovery Room, Radiology Office, Room 201 Bathroom, and Room 203 Bathroom.

3. During a tour of the facility on January 9, 2012 from 12:30 to 7 pm, and January 10, 2012 from 8:20 to 11:19 am, painted and textured fire sprinkler heads were found outside of the Surgery area, in the Lab Reception area, at the Entrance to the ED, in the Triage Room and Hallway of the ED, in 414 Acute Care Director's Office, and in the Utility Room by Room 432.

4. On January 10, 2012 at 6:33 pm, ceiling tiles were missing in the Kitchen and the Tray Return area of the Cafeteria.

Based on observations it was determined that the facility failed to ensure the sprinkler system is continuously maintained & in reliable operating condition. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 (1999) 5-15.2.3.5, 1998 NFPA 25 2-2.1.1). Surveyor was accompanied by the Vice President of Facilities and Director of Engineering who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 10, 2012 at 1:42 pm, the Fire Department Connection for the fire sprinkler system was not marked "FDC" in 6-inch block letters on a red and white sign.

2. On January 10,2012 at 1:52 pm, a fire sprinkler head in the Storage Room by the entrance of Suite 201 was covered in dry wall texture.

Based on observations and record review it was determined that the facility failed to maintain fire extinguishers. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Surveyor was accompanied by the Director of Engineering and Maintenance staff who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 9, 2012 at 2:20 pm, a review of the annual service report for fire extinguishers for the facility indicated that 17 of the extinguishers were past due for the hydrostatic test required every 6 years.

Based upon record reviews and observations it was determined that the facility failed to ensure safe smoking practices by persons on facility grounds in accordance with facility policies and life safety regulations. This resulted in the potential for exposing visitors, patients and staff to a fire and/or smoke environment (LSC 19.7.4). Surveyor was accompanied by the Director of Engineering and Maintenance staff who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 9, 2012 at 12:30 pm, cigarette butts were found improperly discarded at the Main Entrance to the facility. There were no receptacles provided in the area, and "No Smoking" signs were posted. Per review of facility policies, "Security, Facility Managers and Supervisors are responsible for monitoring smoking policy".

Based on observations it was determined that the facility failed to properly install building service equipment. This resulted in the potential for a gas leak and unexpected fire (LSC 19.5.2.1, 19.5.2.2, 9.2, NFPA 90A, ASHRAE 15). Surveyor was accompanied by the Maintenance Supervisor and Administrator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 9, 2012 at 5:19 pm, there was no refrigerant leak alarm notification outside the Chiller Room.

Based on observations it was determined 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, 19.3.2.6, NFPA 96 A.1.1.4, UL300). Surveyor was accompanied by the Director of Engineering and Maintenance staff who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 9, 2012 at 6:32 pm, the grease filters for the Kitchen Hood were not properly aligned.

2. On January 9, 2012 at 6:39 pm, the pull station serving the UL 300 Hood Suppression System in the Kitchen was located less than 10-feet from the deep fat fryer, and was not placed in the path of egress.

Based upon observations and interviews it was determined that the facility failed to ensure that no curtains of highly flammable character were used. This resulted in the potential for excessive fire spread (LSC 19.7.5.1). Surveyor was accompanied by the Director of Engineering and Maintenance staff who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 10, 2012 at 8:58 am, the privacy curtains in the X-Ray Dressing Area were not documented as being flame resistant per NFPA 701. This condition also existed in the Surgical Waiting Room area.

Based on observations, record review and interviews it was determined that the facility failed to provide safe storage for compressed gas. This resulted in the potential for compressed gas tanks to tip over, possibly resulting in an unintentional discharge of compressed gas (LSC 19.3.2.4, 4.3.1.1.2). Surveyor was accompanied by the Director of Engineering and Maintenance staff who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. During a tour of the facility on January 9, 2012 from 12:30 to 7 pm, and January 10, 2012 from 8:20 to 11:19 am, a nitrogen tank was found unsecured in the Chiller Room, the tanks in the Med Gas Room were secured with only one chain, and the compressed gas stored in the Bacteriology area of the Lab was secured with a single chain.

Based on observations and record review it was determined that the facility failed to properly maintain the generator. This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, 6-4.2, NFPA 99, 3.4.4.1) Surveyor was accompanied by the Director of Engineering and Maintenance staff who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 9, 2012 at 2:30 pm, a review of maintenance records for the emergency generators indicated that staff were not documenting the specific gravity of the battery electrolyte levels weekly, only that they were "good". Staff also were not documenting the run hours during monthly testing.

2. On January 9, 2012 at 5:12 pm, there was no battery-powered light provided to illuminate the generator transfer switch.

Based on observations it was determined that the facility failed to properly maintain the generator. This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, 3-5.5.2) Surveyor was accompanied by the Vice President of Facilities and Director of Engineering who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 10, 2012 at 1:47 pm, the emergency shut-off button for the generator was installed inside the cabinet.

Based on observations it was determined that the facility failed to ensure that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to residents & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Surveyor was accompanied by the Director of Engineering and Maintenance staff who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. During a tour of the facility on January 9, 2012 from 12:30 to 7 pm, and January 10, 2012 from 8:20 to 11:19 am, relocatable power taps were found on the floor, permanently attached, not-approved for the use or daisy-chained together in the following locations: OR 2, OR Recovery, OR Reception, MRI Control Area, Carpenter Shop, at the Paging System, PQS Office, Pharmacy, at the Fish Tank in the Lobby, Rear Switchboard Office, Room 220-2, X-Ray Side Office, Room 261, in the EMS Office, Lab Breakroom, Nursery, Health Library, COW Charging Room, ICU Bed 2 and serving the DEKO Link in the Penthouse.

2. On January 9, 2012 at 5:10 pm, a junction box in the Carpenter Shop was not secured to the wall.

3. On January 9, 2012 at 5:20 pm, Nitrogen and Refrigerant tanks were blocking access to the electrical panels in the Chiller Room.

4. On January 9, 2012 at 5:37 pm, the electrical outlet near the sink was not marked as GFCI protected in the Dirty Laundry Room on the Lower Level. This condition also existed in the Dirty Utility Room on the Third Floor.

5. On January 9, 2012 at 6:12 pm, an open junction box was located in the Sprinkler Control Room. This condition also existed above the ceiling tile near the entrance to Surgery, and the box was also recessed into the wall.

6. On January 10, 2012 at 9 am, a broken electrical cover plate was found in the CT Scan Room.

7. On January 10, 2012 9:18 am, an electrical outlet was damaged in Room 261.

Based on observations it was determined that the facility failed to ensure that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to residents & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Surveyor was accompanied by the Vice President of Facilities and Director of Engineering who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 10, 2012 at 1:55 pm, a relocatable power tap was found on the floor of the Nursing POD Station.

Based on observations it was determined that the facility failed to install alcohol gel hand sanitizing dispensing stations away from sources of ignition and a minimum of 4' spacing between dispensers. This resulted in the potential for injury to residents and staff (CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623). Surveyor was accompanied by the Director of Engineering and Maintenance staff who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. During a tour of the facility on January 9, 2012 from 12:30 to 7 pm, and January 10, 2012 from 8:20 to 11:19 am, alcohol hand sanitizer dispensers were mounted above electrical connections in OR 2, ED Office Staff Room and Room 433.

Based on observations it was determined that the facility failed to install alcohol gel hand sanitizing dispensing stations away from sources of ignition and a minimum of 4' spacing between dispensers. This resulted in the potential for injury to residents and staff (LSC 18.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623). Surveyor was accompanied by the Vice President of Facilities and Director of Engineering
who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On January 10, 2012 at 1:53 pm, an alcohol-based hand sanitizer was installed above the light switch in the East Provider's Office.