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Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facilities and Hospital Engineer that the facility failed to separate sections of health care facilities from non-healthcare facilities. 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). Findings include, but are not limited to:
1. On 1/9/2014, at 8:51 a.m., there were 2-1 1/2" wall penetrations within the 2hr. fire wall adjacent to Rm. 346.
2. On 1/9/2014, at 9:25 a.m., there was a 24"x24" wall penetrations within the 2hr. fire wall on the third floor at the '65 Building and an unsealed horizontal penetration approximately 12' long at the top of the 2hr. barrier adjacent to staff elevator lobby on the 3rd floor.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facilities and Hospital Engineer that the facility failed to maintain the integrity of smoke separations for hazardous rooms. This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of patients & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Findings include, but are not limited to:
1. On 1/9/2014, at 9:20 a.m., there was a 1"x2" wall penetrations in the electrical room on Floor 3 across from the Nurse Managers Office.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Quality Manager that the facility failed to maintain the integrity of smoke separations for hazardous rooms. This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of patients & staff to hazardous products of fire (LSC 39.3.2). Findings include, but are not limited to:
1. On 1/9/2014, at 10:54 a.m., there were multiple wall penetrations within the main electrical room ranging from approximately 1/2" - 3" holes,12"x12" and 12"x18" rectangular penetrations.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facilities and Hospital Engineer that the facility failed to properly identify exits that were not readily apparent. This resulted in the potential for panic and confusion during an evacuation (LSC 7.10.1.4). Findings include, but are not limited to:
1. On 1/9/2014, at 10:55 a.m., there was missing exit signage within the chapel.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facilities and Hospital Engineer that the facility failed to provide a one hour separation between hazardous areas and the corridor. This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 19.3.2). Findings include, but are not limited to:
1. On 1/8/2014, at 2:30 p.m., there was a missing door closure Rm. 458 that was converted from a Patient room to a Storage Room.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Environmental Quality Manager 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 39.7.1). Findings include, but are not limited to:
1. On 1/9/2014, during record review between 12:30 p.m. to 1:30 p.m., the disaster plan provided by the facility to the surveyor did not have a map of the facilities utility shutoffs. Safety Binder also references the use of "Dr. Red".

Based on interviews and record review during the survey, it was determined through on-going dialog with the Director of Facilities and Hospital Engineer 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 patients to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2). Findings include, but are not limited to:
1. On 1/8/2014, during record review between 8:00 a.m. and 12:00 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as number of simulated patients relocated and time to complete simulated relocation. Swing and Night shift drills for 2013 and 2012 were not being staggered throughout the shifts and there was missing fire drill documentation for swing shift, 2nd quarter in 2012.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Environmental Quality Manager 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 39.7.1). Findings include, but are not limited to:
1. On 1/9/2014, during record review between 12:30 p.m. and 1:30 p.m., there was a missing fire drill for the year of 2012. Fire drill documentation provided to the surveyor was missing information such as location of the fire and type of fire. Fire drill documentation was also not being maintained on site.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facilities and Hospital Engineer that the facility failed to install fire alarm system in accordance with NFPA 72 "private mode" systems. This resulted in the potential for delay and panic during fire emergencies (LSC 19.3.4, 9.6). Findings include, but are not limited to:
1. On 1/8/2014, at 2:47 p.m., there were fire alarm notification devices within Rehab Dining/Activity Room on Floor 4 within the ACE Unit which are prohibited in patient treatment areas per NFPA 72 for "private mode" systems.
2. On 1/9/2014, at 9:20 a.m., the fire alarm panel was in trouble since 12/13/13 and there was no record or documentation shown in correcting the problem.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Quality Manager that the facility failed to install fire alarm system in accordance with NFPA 72 systems. This resulted in the potential for system and device failure during fire emergencies (LSC 39.3.4, 9.6). Findings include, but are not limited to:
1. On 1/9/2014, at 10:53 a.m., there was a missing set screw lock on the breaker for the Fire Alarm Control Panel and no red FACP label beside breaker #15. The location for the breaker for the FACP was not identified on the door of the FACP.
2. On 1/9/2014, at 11:01 a.m., there was missing signage of the door leading to the fire alarm control panel.

Based on record review and interview during the survey, it was determined through on-going dialog with the Environmental Quality Manager 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. On 1/9/2014, during record review between 12:30 p.m. and 1:30 p.m., there was no maintenance documentation or maintenance records being kept on site for the fire alarm system.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Quality Manager 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 39.3.5, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. On 1/9/2014, at 11:01 a.m., there was missing signage on the door leading to the fire sprinkler riser room and the spare sprinkler head cabinet was missing a minimum of 2 sidewall sprinkler heads.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facilities and Hospital Engineer 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:
1. On 1/9/2014, at 9:30 a.m., there were two Fire Department Connections on Hilyard Street that were missing 6" "FDC" letters and labels to what they serve.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Environmental Quality Manager 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 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:
1. On 1/9/2014, at 11:01 a.m., the gauges on the fire sprinkler riser were dated 2007 and were past due for replacement or recalibration since 2012. There was a Fire Department Connection on the side of the building that was missing 6" "FDC" letter signage.
2. On 1/9/2014, during record review between 12:30 p.m. and 1:30 p.m., there was no maintenance documentation or maintenance records being kept on site for the fire sprinkler system.

Based on record review and interview during the survey, it was determined through on-going dialog with the Environmental Quality Manager 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:
1. On 1/9/2014, during record review between 12:30 p.m. and 1:30 p.m., the facility had not conducted the required annual forward flow test of the sprinkler system.

Based on observations and interviews it was determined through on-going dialog with the Director of Facilities and Hospital Engineer 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 19.3.2.4, NFPA 99 4.3.1.1.2). Findings include, but are not limited to:
1. On 1/8/2014, at 3:30 p.m., there were 6 oxygen cylinders stored within a soiled utility room outside of radiology that had electrical within 60" of the finish floor.
2. On 1/8/2014, at 3:38 p.m., there were 16 oxygen cylinders stored within a storage room in Respiratory Therapy that had electrical within 60" of the finish floor.

Based on observations, interviews it was determined through on-going dialog with the Director of Facilities and Hospital Engineer 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, NFPA 99, 3.4.4.1, 6.4.2). Findings include, but are not limited to:
1. On 1/9/2014, at 8:32 a.m., there was less then 80% of fuel within the fuel tank of the generators; only 8800 gallons for a 12,000 gallon tank.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facilities and Hospital Engineer 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 patients & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:
1. On 1/8/2014, at 2:28 p.m., there were relocatable power taps on the floor within Rm. 441, 442, 457 and Rm. 467.
2. On 1/8/2014, at 3:43 p.m., there was a missing face plate on an electrical outlet within an IT Office. There were relocatable power taps plugged into the outlet.
3. On 1/8/2014, at 3:48 p.m., there were household microwaves and a household coffee pot within the 4th Floor Imaging North Breakroom.
4. On 1/9/2014, at 9:11 a.m., there were relocatable power taps on the floor within Behavioral Health Guest Office, Clinical Managers Office, Consult Room and Nurse Managers Office on floor 3.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Quality Manager 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 patients & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:
1. On 1/9/2014, at 11:01 a.m., there was an electrical box adjacent to the fire sprinkler riser missing a cover.
2. On 1/9/2014, at 11:12 a.m., there was a microwave and toaster oven plugged into a relocatable power tap within Storage Rm. 1120.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facilities and Hospital Engineer that the facility failed to separate sections of health care facilities from non-healthcare facilities. 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). Findings include, but are not limited to:
1. On 1/9/2014, at 8:51 a.m., there were 2-1 1/2" wall penetrations within the 2hr. fire wall adjacent to Rm. 346.
2. On 1/9/2014, at 9:25 a.m., there was a 24"x24" wall penetrations within the 2hr. fire wall on the third floor at the '65 Building and an unsealed horizontal penetration approximately 12' long at the top of the 2hr. barrier adjacent to staff elevator lobby on the 3rd floor.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facilities and Hospital Engineer that the facility failed to maintain the integrity of smoke separations for hazardous rooms. This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of patients & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Findings include, but are not limited to:
1. On 1/9/2014, at 9:20 a.m., there was a 1"x2" wall penetrations in the electrical room on Floor 3 across from the Nurse Managers Office.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Quality Manager that the facility failed to maintain the integrity of smoke separations for hazardous rooms. This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of patients & staff to hazardous products of fire (LSC 39.3.2). Findings include, but are not limited to:
1. On 1/9/2014, at 10:54 a.m., there were multiple wall penetrations within the main electrical room ranging from approximately 1/2" - 3" holes,12"x12" and 12"x18" rectangular penetrations.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facilities and Hospital Engineer that the facility failed to properly identify exits that were not readily apparent. This resulted in the potential for panic and confusion during an evacuation (LSC 7.10.1.4). Findings include, but are not limited to:
1. On 1/9/2014, at 10:55 a.m., there was missing exit signage within the chapel.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facilities and Hospital Engineer that the facility failed to provide a one hour separation between hazardous areas and the corridor. This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 19.3.2). Findings include, but are not limited to:
1. On 1/8/2014, at 2:30 p.m., there was a missing door closure Rm. 458 that was converted from a Patient room to a Storage Room.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Environmental Quality Manager 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 39.7.1). Findings include, but are not limited to:
1. On 1/9/2014, during record review between 12:30 p.m. to 1:30 p.m., the disaster plan provided by the facility to the surveyor did not have a map of the facilities utility shutoffs. Safety Binder also references the use of "Dr. Red".

Based on interviews and record review during the survey, it was determined through on-going dialog with the Director of Facilities and Hospital Engineer 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 patients to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2). Findings include, but are not limited to:
1. On 1/8/2014, during record review between 8:00 a.m. and 12:00 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as number of simulated patients relocated and time to complete simulated relocation. Swing and Night shift drills for 2013 and 2012 were not being staggered throughout the shifts and there was missing fire drill documentation for swing shift, 2nd quarter in 2012.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Environmental Quality Manager 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 39.7.1). Findings include, but are not limited to:
1. On 1/9/2014, during record review between 12:30 p.m. and 1:30 p.m., there was a missing fire drill for the year of 2012. Fire drill documentation provided to the surveyor was missing information such as location of the fire and type of fire. Fire drill documentation was also not being maintained on site.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facilities and Hospital Engineer that the facility failed to install fire alarm system in accordance with NFPA 72 "private mode" systems. This resulted in the potential for delay and panic during fire emergencies (LSC 19.3.4, 9.6). Findings include, but are not limited to:
1. On 1/8/2014, at 2:47 p.m., there were fire alarm notification devices within Rehab Dining/Activity Room on Floor 4 within the ACE Unit which are prohibited in patient treatment areas per NFPA 72 for "private mode" systems.
2. On 1/9/2014, at 9:20 a.m., the fire alarm panel was in trouble since 12/13/13 and there was no record or documentation shown in correcting the problem.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Quality Manager that the facility failed to install fire alarm system in accordance with NFPA 72 systems. This resulted in the potential for system and device failure during fire emergencies (LSC 39.3.4, 9.6). Findings include, but are not limited to:
1. On 1/9/2014, at 10:53 a.m., there was a missing set screw lock on the breaker for the Fire Alarm Control Panel and no red FACP label beside breaker #15. The location for the breaker for the FACP was not identified on the door of the FACP.
2. On 1/9/2014, at 11:01 a.m., there was missing signage of the door leading to the fire alarm control panel.

Based on record review and interview during the survey, it was determined through on-going dialog with the Environmental Quality Manager 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. On 1/9/2014, during record review between 12:30 p.m. and 1:30 p.m., there was no maintenance documentation or maintenance records being kept on site for the fire alarm system.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Quality Manager 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 39.3.5, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. On 1/9/2014, at 11:01 a.m., there was missing signage on the door leading to the fire sprinkler riser room and the spare sprinkler head cabinet was missing a minimum of 2 sidewall sprinkler heads.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facilities and Hospital Engineer 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:
1. On 1/9/2014, at 9:30 a.m., there were two Fire Department Connections on Hilyard Street that were missing 6" "FDC" letters and labels to what they serve.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Environmental Quality Manager 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 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:
1. On 1/9/2014, at 11:01 a.m., the gauges on the fire sprinkler riser were dated 2007 and were past due for replacement or recalibration since 2012. There was a Fire Department Connection on the side of the building that was missing 6" "FDC" letter signage.
2. On 1/9/2014, during record review between 12:30 p.m. and 1:30 p.m., there was no maintenance documentation or maintenance records being kept on site for the fire sprinkler system.

Based on record review and interview during the survey, it was determined through on-going dialog with the Environmental Quality Manager 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:
1. On 1/9/2014, during record review between 12:30 p.m. and 1:30 p.m., the facility had not conducted the required annual forward flow test of the sprinkler system.

Based on observations and interviews it was determined through on-going dialog with the Director of Facilities and Hospital Engineer 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 19.3.2.4, NFPA 99 4.3.1.1.2). Findings include, but are not limited to:
1. On 1/8/2014, at 3:30 p.m., there were 6 oxygen cylinders stored within a soiled utility room outside of radiology that had electrical within 60" of the finish floor.
2. On 1/8/2014, at 3:38 p.m., there were 16 oxygen cylinders stored within a storage room in Respiratory Therapy that had electrical within 60" of the finish floor.

Based on observations, interviews it was determined through on-going dialog with the Director of Facilities and Hospital Engineer 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, NFPA 99, 3.4.4.1, 6.4.2). Findings include, but are not limited to:
1. On 1/9/2014, at 8:32 a.m., there was less then 80% of fuel within the fuel tank of the generators; only 8800 gallons for a 12,000 gallon tank.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facilities and Hospital Engineer 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 patients & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:
1. On 1/8/2014, at 2:28 p.m., there were relocatable power taps on the floor within Rm. 441, 442, 457 and Rm. 467.
2. On 1/8/2014, at 3:43 p.m., there was a missing face plate on an electrical outlet within an IT Office. There were relocatable power taps plugged into the outlet.
3. On 1/8/2014, at 3:48 p.m., there were household microwaves and a household coffee pot within the 4th Floor Imaging North Breakroom.
4. On 1/9/2014, at 9:11 a.m., there were relocatable power taps on the floor within Behavioral Health Guest Office, Clinical Managers Office, Consult Room and Nurse Managers Office on floor 3.

Based on observations and interview during the survey, it was determined through on-going dialog with the Environmental Quality Manager 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 patients & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:
1. On 1/9/2014, at 11:01 a.m., there was an electrical box adjacent to the fire sprinkler riser missing a cover.
2. On 1/9/2014, at 11:12 a.m., there was a microwave and toaster oven plugged into a relocatable power tap within Storage Rm. 1120.