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Based on observations, the facility failed to maintain required fire/smoke barriers to resist the passage of smoke and flames which could endanger the patients, staff, and other building occupants.

The findings include:

1. On July 23, 2013 at 12:45 PM while on tour with facility staff, on the 10th floor in the Fountain Tower at the South Cross Corridor doors it was observed that the left door leaf was out of alignment and made the door drag on the floor failing to allow the door to come to a fully closed position in accordance with NFPA 80 (1999) 15-2.1, 15-2.1.1, 15-2.4.1, 15-2.4.2, 15-2.5.3, NFPA 101 (2000) 4.6.12.1, 7.2.1.5.4, 19.2.2.2.1, 19.3.6.3.2, 19.7.6.

2. On July 23, 2013 at 2:20 PM while on tour with facility staff, on the 5th floor in the Fountain Tower at the elevator lobby it was observed that the women's restroom door was out of alignment with the frame and would not come to a fully closed position in accordance with NFPA 80 (1999) 15-2.1, 15-2.1.1, 15-2.4.1, 15-2.4.2, 15-2.5.3, NFPA 101 (2000) 4.6.12.1, 7.2.1.5.4, 19.2.2.2.1, 19.3.6.3.2, 19.7.6.

3. On July 24, 2013 at 9:07 AM while on tour with facility staff, at the Cafe in the France Tower it was observed that the entry door to the kitchen by the front register failed to latch in the closed position due to the door being out of alignment which is not in accordance with NFPA 80 (1999) 15-2.1, 15-2.1.1, 15-2.4.1, 15-2.4.2, 15-2.5.3, NFPA 101 (2000) 4.6.12.1, 7.2.1.5.4, 19.2.2.2.1, 19.3.6.3.2, 19.7.6.

Based on record reviews, the facility failed to provide evidence of fire drills being conducted at unexpected times under various conditions at least once per shift per quarter, which can lead to failure of the facility staff to perform properly during emergency events, and which can lead to injury or loss of patients, staff, or other building occupants.

The findings include:

On July 22, 2013 from 11:50 AM to 12:55 PM during record reviews with staff, the documentation of the facility's fire drills showed that the facility performed drills for the 2nd shift during the past year at 3:36 PM, 3:20 PM, 4:00 PM, and 3:30 PM; 3rd shift was at 6:06 AM, 5:00 AM, 6:17 AM and 6:15 AM. These times are not varied throughout the shift to keep staff from becoming familiar with drill times, which can lead to a lapse in response to an actual emergency, which is not in accordance with NFPA 101 (2000) 4.7.1, 4.7.2, 4.7.3, 4.7.4, 4.7.5, 4.7.6, 19.7.1.2.

These findings were confirmed with the Maintenance Supervisor, Biomedical Coordinator, Facility Maintenance Operations Manager, Safety/Emergency Preparations Operations Coordinator, Security & Safety Manager, and Electrical Supervisor July 24, 2013 at 3:45 PM.

Based on observations, the facility failed to maintain storage of compressed gasses in accordance with NFPA 99, Standard for Health Care Facilities endangering the patients, staff, and other building occupants.

The findings include:

1. On July 24, 2013 at 10:33 AM while on tour with facility staff, at the CEO Building in the compressed gas cylinder storage yard it was observed a total of 25 h-sized cylinders were in storage with no protection from tipping or falling. In discussion with the Facility Operations Manager he advised that it was found that the bottles were being exchanged with new, upon complete discharge, and they were not properly relocated to the assigned storage location; a new policy will be put in place to verify proper storage practices during routine sweeps in accordance with NFPA 99 (1999) 4-3.1.1.2(a)(3), 4-3.1.1.8(a), 4-3.5.2.1(b)(27), 4-3.5.2.2(b)(2), 4-4.5.2, 4-5.1.1.1, 8-3.1.11.2, NFPA 101 (2000) 4.6.12.1, 19.3.2.4, 19.7.6.

Based on observations, the facility failed to maintain electrical equipment and wiring, in accordance with the National Electric Code (N.E.C.), NFPA 70, which could endanger patients, staff, or other building occupants.

The findings include:

1. On July 23, 2013 at 1:35 PM while on tour with facility staff, on the 8th floor of the Fountain Tower in the Communications Closet it was observed a multi-plug power strip device in use in lieu of proper outlet power for electronic equipment, in accordance with NFPA 70 (1999) Article 400-7, 400-8, NFPA 99 (1999) 3-1.2, 3-3.2.1.1, NFPA 101 (2000) 9.1.2, 19.5.1.

2. On July 24, 2013 at 9:01 AM while on tour with facility staff, at the France Tower Cafe in the kitchen electrical Panels NBL1C circuits 32, 36, 38 and Panel QB1L2 circuits 27, 41 were identified on the circuit legend as being spares, but were in the 'on' position in use. Panel legend shall be properly labeled as to circuit controls in accordance with NFPA 70 (1999) Article 110-22, NFPA 101 (2000) 9.1.2, 19.5.1.

3. On July 24, 2013 at 10:40 AM while on tour with facility staff, at the CEO Building in the Medical Air Compressor Room, it was observed that Med Air System #1 was utilizing an electrical extension cord for an auto electric air valve device in lieu of proper electrical power, in accordance with NFPA 70 (1999) Article 400-7, 400-8, NFPA 99 (1999) 3-1.2, 3-3.2.1.1, NFPA 101 (2000) 9.1.2, 19.5.1.

These findings were confirmed with the Maintenance Supervisor, Biomedical Coordinator; Facility Maintenance Operations Manager; Safety/Emergency Preparations Operations Coordinator; Security & Safety Manager; and Electrical Supervisor on July 24, 2013 at 3:45 PM.

Based on observations, the facility failed to maintain required fire/smoke barriers to resist the passage of smoke and flames which could endanger the patients, staff, and other building occupants.

The findings include:

1. On July 23, 2013 at 12:45 PM while on tour with facility staff, on the 10th floor in the Fountain Tower at the South Cross Corridor doors it was observed that the left door leaf was out of alignment and made the door drag on the floor failing to allow the door to come to a fully closed position in accordance with NFPA 80 (1999) 15-2.1, 15-2.1.1, 15-2.4.1, 15-2.4.2, 15-2.5.3, NFPA 101 (2000) 4.6.12.1, 7.2.1.5.4, 19.2.2.2.1, 19.3.6.3.2, 19.7.6.

2. On July 23, 2013 at 2:20 PM while on tour with facility staff, on the 5th floor in the Fountain Tower at the elevator lobby it was observed that the women's restroom door was out of alignment with the frame and would not come to a fully closed position in accordance with NFPA 80 (1999) 15-2.1, 15-2.1.1, 15-2.4.1, 15-2.4.2, 15-2.5.3, NFPA 101 (2000) 4.6.12.1, 7.2.1.5.4, 19.2.2.2.1, 19.3.6.3.2, 19.7.6.

3. On July 24, 2013 at 9:07 AM while on tour with facility staff, at the Cafe in the France Tower it was observed that the entry door to the kitchen by the front register failed to latch in the closed position due to the door being out of alignment which is not in accordance with NFPA 80 (1999) 15-2.1, 15-2.1.1, 15-2.4.1, 15-2.4.2, 15-2.5.3, NFPA 101 (2000) 4.6.12.1, 7.2.1.5.4, 19.2.2.2.1, 19.3.6.3.2, 19.7.6.

Based on record reviews, the facility failed to provide evidence of fire drills being conducted at unexpected times under various conditions at least once per shift per quarter, which can lead to failure of the facility staff to perform properly during emergency events, and which can lead to injury or loss of patients, staff, or other building occupants.

The findings include:

On July 22, 2013 from 11:50 AM to 12:55 PM during record reviews with staff, the documentation of the facility's fire drills showed that the facility performed drills for the 2nd shift during the past year at 3:36 PM, 3:20 PM, 4:00 PM, and 3:30 PM; 3rd shift was at 6:06 AM, 5:00 AM, 6:17 AM and 6:15 AM. These times are not varied throughout the shift to keep staff from becoming familiar with drill times, which can lead to a lapse in response to an actual emergency, which is not in accordance with NFPA 101 (2000) 4.7.1, 4.7.2, 4.7.3, 4.7.4, 4.7.5, 4.7.6, 19.7.1.2.

These findings were confirmed with the Maintenance Supervisor, Biomedical Coordinator, Facility Maintenance Operations Manager, Safety/Emergency Preparations Operations Coordinator, Security & Safety Manager, and Electrical Supervisor July 24, 2013 at 3:45 PM.

Based on observations, the facility failed to maintain storage of compressed gasses in accordance with NFPA 99, Standard for Health Care Facilities endangering the patients, staff, and other building occupants.

The findings include:

1. On July 24, 2013 at 10:33 AM while on tour with facility staff, at the CEO Building in the compressed gas cylinder storage yard it was observed a total of 25 h-sized cylinders were in storage with no protection from tipping or falling. In discussion with the Facility Operations Manager he advised that it was found that the bottles were being exchanged with new, upon complete discharge, and they were not properly relocated to the assigned storage location; a new policy will be put in place to verify proper storage practices during routine sweeps in accordance with NFPA 99 (1999) 4-3.1.1.2(a)(3), 4-3.1.1.8(a), 4-3.5.2.1(b)(27), 4-3.5.2.2(b)(2), 4-4.5.2, 4-5.1.1.1, 8-3.1.11.2, NFPA 101 (2000) 4.6.12.1, 19.3.2.4, 19.7.6.

Based on observations, the facility failed to maintain electrical equipment and wiring, in accordance with the National Electric Code (N.E.C.), NFPA 70, which could endanger patients, staff, or other building occupants.

The findings include:

1. On July 23, 2013 at 1:35 PM while on tour with facility staff, on the 8th floor of the Fountain Tower in the Communications Closet it was observed a multi-plug power strip device in use in lieu of proper outlet power for electronic equipment, in accordance with NFPA 70 (1999) Article 400-7, 400-8, NFPA 99 (1999) 3-1.2, 3-3.2.1.1, NFPA 101 (2000) 9.1.2, 19.5.1.

2. On July 24, 2013 at 9:01 AM while on tour with facility staff, at the France Tower Cafe in the kitchen electrical Panels NBL1C circuits 32, 36, 38 and Panel QB1L2 circuits 27, 41 were identified on the circuit legend as being spares, but were in the 'on' position in use. Panel legend shall be properly labeled as to circuit controls in accordance with NFPA 70 (1999) Article 110-22, NFPA 101 (2000) 9.1.2, 19.5.1.

3. On July 24, 2013 at 10:40 AM while on tour with facility staff, at the CEO Building in the Medical Air Compressor Room, it was observed that Med Air System #1 was utilizing an electrical extension cord for an auto electric air valve device in lieu of proper electrical power, in accordance with NFPA 70 (1999) Article 400-7, 400-8, NFPA 99 (1999) 3-1.2, 3-3.2.1.1, NFPA 101 (2000) 9.1.2, 19.5.1.

These findings were confirmed with the Maintenance Supervisor, Biomedical Coordinator; Facility Maintenance Operations Manager; Safety/Emergency Preparations Operations Coordinator; Security & Safety Manager; and Electrical Supervisor on July 24, 2013 at 3:45 PM.