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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 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 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 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.