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Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff that the facility failed to provide a one hour separation between hazardous areas and the products of fire during a hostile fire event (LSC 19.3.2). Findings include, but are not limited corridor. This resulted in the potential for patients & staff to be exposed to hazardous to:
1. On 2/5/2014, at 11:20 a.m., the double doors opening from Materials Services (B-122) into a facility corridor was not closing or latching properly.

Based on record review and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 patients & staff during emergency evacuation conditions (LSC 19.2.8). Findings include, but are not limited to:
1. On 2/4/2014, during record review between, 1:00 p.m. and 4:30 p.m., there was no documentation showing the required monthly 30 second test or annual 90 minute test on emergency lights within the facility.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 19.7.1.1). Findings include, but are not limited to:
1. On 2/4/2014, during record review, between 1:00 p.m. and 4:30 p.m., there were phone lists within the Disaster Plan that had staff members listed that are no longer employed with the facility. The review dates for the phone lists were not current for Accounting, Volunteers, Case Management, Human Resources, Education and Medical Records.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 2/4/2014, during record review between, 1:00 p.m. and 4:30 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as type of simulated fire, number of simulated occupants evacuated and time of simulated patient evacuation. Fire Drills in May 2013 were completed as "Coded Announcement" drills after 6:00 a.m. Facility was also missing 1st Quarter Day Shift Drill in 2013.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 2/4/2014, at 4:30 p.m., there were fire alarm notification devices within the OR #1, OR #2, OR #3, OR #4, OR #5 and OR #6 which are prohibited in patient treatment/care areas per NFPA 72 for "private mode" systems.
2. On 2/5/2014, at 9:00 a.m. there were fire alarm notification devices within patient treatment/care areas in Unit B, Unit C, ICU, Diagnostic Imaging, Emergency Department Exam Rooms and Day Surgery which are prohibited in patient treatment/care areas per NFPA 72 for "private mode" systems.
3. On 2/5/2014, at 10:46 a.m., there were missing notification devices outside the doors leading to the chiller room.

Based on record review and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff that the facility failed to test and maintain fire alarm in accordance with NFPA 72 for the entire building. 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 2/4/2014, during record review, between 1:00 p.m. and 4:30 p.m., monthly and quarterly maintenance/testing was being performed by staff and there was no documentation showing technician competence and testing and maintenance documentation was incomplete, missing information on testing and maintenance that was performed in maintaining the fire alarm system.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 19.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. On 2/5/2014, at 10:03 a.m., there was missing sprinkler coverage in oversized skylight pockets (exceeding 32 sq. ft.) in Patient Rm. A-224 and at Unit A Patio area.
2. On 2/5/2014, between 10:54 a.m. and 11:05 a.m., there were dry sprinkler system air compressors that did not have a locks on the on/off switches for the Emergency Department system, North Addition system and Imaging system.
3. On 2/5/2014, between 11:38 a.m. and 2:37 p.m., there were missing escutcheon rings on sprinkler heads in the following location but not limited to Hallway outside of PACU, Patient Rm. A, Walk in Freezer in Kitchen and adjacent to IT.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 2/4/2014, during record review, between 1:00 p.m. and 4:30 p.m., weekly, monthly and quarterly testing/maintenance was being performed by staff and there was no documentation showing technician competence and testing and maintenance documentation was incomplete, missing information on testing and maintenance that was performed in maintaining the sprinklers. Staff did not have access to the adopted 1998 edition of NFPA 25 standards and there was no record of the required 5yr. IIIC test on the fire sprinkler system.
2. On 2/5/2014, at 10:00 a.m., there was combustible storage consisting of couch cushions stacked within 18" of the sprinkler heads in Family Birth Center Storeroom A-221.
3. On 2/5/2014, at 10:46 a.m., there were gauges on the fire sprinkler riser in the Lower Mechanical Room that were dated 1984 and 2007 and were past due for replacement or recalibration since 1989 and 2012.
4. On 2/5/2014, at 10:50 a.m., there were missing spare sidewall sprinkler heads within the spare sprinkler cabinet at the Lower Mechanical Room.
5. On 2/5/2014, at 10:52 a.m. and 11:05 a.m., there was missing signage (Sprinkler Riser Room) on the doors leading to sprinkler riser in the following areas: Lower Mechanical Room wet/dry system, Emergency Department dry system, North Addition dry system and Imaging dry system.
6. On 2/5/2014, at 10:54 a.m., there were gauges on the dry fire sprinkler riser outside of the Emergency Department that were dated 2007 and 2008 and were past due for replacement of recalibration since 2012 and 2013.
7. On 2/5/2014, at 10:54 a.m., there was missing signage (6" FDC letters; white on red or red on white and what the FDC serves) on the Fire Department Connection adjacent to the Emergency Department.
8. On 2/5/2014, at 11:00 a.m., there were gauges on the dry fire sprinkler riser in the North Addition that were dated 1998 and were past due for replacement of recalibration since 2003.

Based on record review and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 2/4/2014, during record review between, 1:00 p.m. and 4:30 p.m., the facility had not conducted the required annual forward flow test of the sprinkler system, there was no record on when the last test was performed.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff that the facility failed to maintain fire extinguishers in accordance with adopted standards for all extinguishers of the facility. 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). Findings include, but are not limited to:
1. On 2/4/2014, during record review, between 1:00 p.m. and 4:30 p.m., monthly inspections were being performed by staff and staff did not have access to the adopted 1998 edition of NFPA 10 standards.
2. On 2/5/2014, at 2:00 p.m., there was not a minimum sized 10A 120B fire extinguisher located adjacent to the facilities Helicopter Pad only a 2A 10B:C.

Based on record review and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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). Findings include, but are not limited to:
1. On 2/4/2014, during record review, between 1:00 p.m. and 4:30 p.m., the facility had not conducted the required semi-annual kitchen hood/suppression inspection. Testing and maintenance inspections for the kitchen hood were completed on 2/18/2013.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff that the facility failed to prohibit the use of portable space heating devices. This resulted in the potential for ignition of nearby combustibles (LSC 19.7.8). Findings include, but are not limited to:
1. On 2/5/2014, between 9:11 a.m. and 11:10 a.m., there were portable space heaters in use within patient sleeping areas in the following locations but not limited to, Unit B Nurse Managers Office, ED Triage Area and C181 Area.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff that the facility failed to ensure that no furnishings or decorations of highly flammable character are used, unless in limited quantities or flame retardant. This resulted in the potential for excessive fire spread (LSC 19.7.5.4). Findings include, but are not limited to:
1. On 2/5/2014, at 9:17 a.m., there were combustible decorations (quilts) within the Infection Control Office that was not treated with flame retardant materials.

Based on observations and interviews it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 2/5/2014, at 11:17 a.m., there was an oxygen storage room adjacent to Respiratory Therapy that had electrical outlets and switches within 60" of the finished floor.
2. On 2/5/2014, at 2:00 p.m., there was an Medical Gas Storage Room B-104 that had electrical outlets and switches within 60" of the finished floor.

Based on record review and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1. This resulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to:
1. On 2/4/2014, during record review, between 1:00 p.m. and 4:30 p.m., the humidity policy dated 4/2011 that was presented to the surveyor did not specify the adopted humidity range. The policy only mentioned that "CDC Guidelines for Hospitals is reviewed for standards on HVAC, lighting and humidity". The 4/2011 policy did not have recommendations or procedures on what needs to be accomplished when the humidity was not within the adopted/specified range. Humidity levels were measured under the ASHRAE Standard 170 adopted 20% on the following days in the following areas: OR #5 1/31/2014, 2/1-5/2014; OR #6 1/31/2014, 2/1-5/2014; OB 1/4-7/2013, 1/10-15/2013, 1/16-24/2013, 1/27-28/2013, 2/2-3/2013, 2/8/2013, 2/10/2013, 2/14-16/2013, 2/18/2013, 2/22/2013, 2/23-24/2013, 2/26-28/2013, 3/6/2013, 3/11/2013, 3/15/2013, 3/17-27/2013, 4/12/2013, 4/16-18/2013, 4/22-24/2013, 4/27/2013, 4/29-30/2013, 5/2/2013, 5/14-15/2013, 10/29-31/2013, 11/3-4/2013, 11/20-30/2013. 12/3-19/2013, 12/21-24/2013, 12/25-30/2013, 1/31/2014 and 2/1-5/2014. Humidity Records for OR #1-#6 were not available for review for all of 2013, facility switched record programs and data was not archived as mentioned by the Facility Engineer and Maintenance Staff.

Based on record review and interviews it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 2/4/2014, during record review, between 1:00 p.m. and 4:30 p.m., monthly maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the generator and staff did not have access to the 1999 edition NFPA 110 standards. Documentation presented to the surveyor showed a 4hr. load bank test completed on 6/12/2007 which was over due since 6/12/2010 . Other facility documentation showed only a 2hr. load bank test performed 6/2011 and 6/2010 and not the required 3yr. 4hr. 80% load bank test.

Based on record review and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff that the facility failed to provide an alternate source of power in accordance with NFPA 99 3.6, for lighting at the generator and generator transfer switch which would provide a minimum of 90 minutes of power in an outage. This resulted in the potential for panic and confusion for staff and patients in a power outage. Findings include, but are not limited to:
1. On 2/4/2014, during record review, between 1:00 p.m. and 4:30 p.m., there was no documentation showing the required monthly 30 second test or annual 90 minute test on emergency lights within the generator enclosure or generator transfer switch.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 2/4/2014, at 4:32 p.m., there was a non-patient relocatable power tap (RPT) within OR #1.
2. On 2/4/2014, at 4:46 p.m., there was an extension cord in use within the C-Section Room.
3. On 2/5/2014, between 9:26 a.m. and 2:38 p.m., there were relocatable power taps and extension cords in use or daisy chained together within the following areas but not limited to the Sleep Lab Control Room, Emergency ROM Triage C-179, Material Services B-122, South Dietary Office and IT Office.
4. On 2/5/2014, at 11:00 a.m., there were residential heating/cooking appliances in use in the Emergency Department Employee break room and PACU Employee break room.
5. On 2/5/2014, at 11:15 a.m., there were non-patient relocatable power taps (RPTs) in the following areas but not limited to, Emergency Triage C-179 and ED Nurse Station.

Based on the observations and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff that the facility failed to install alcohol gel hand sanitizing dispensing stations away from sources of ignition. This resulted in the potential for injury to patients and staff (LSC 19.3.2.6, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623). Findings include, but are not limited to:
1. On 2/4/2014, at 4:40 p.m., there was an Alcohol Based Hand Rub (ABHR) station that was installed above an electrical switch within the OR Sterile Corridor.
2. On 2/5/2014, at 11:25 a.m., there were Alcohol Based Hand Rub (ABHR) stations that were installed above electrical switches and electrical outlets outside a Public Restroom adjacent to the ED Waiting area and in the PACU adjacent to A-154.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff that the facility failed to provide a one hour separation between hazardous areas and the products of fire during a hostile fire event (LSC 19.3.2). Findings include, but are not limited corridor. This resulted in the potential for patients & staff to be exposed to hazardous to:
1. On 2/5/2014, at 11:20 a.m., the double doors opening from Materials Services (B-122) into a facility corridor was not closing or latching properly.

Based on record review and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 patients & staff during emergency evacuation conditions (LSC 19.2.8). Findings include, but are not limited to:
1. On 2/4/2014, during record review between, 1:00 p.m. and 4:30 p.m., there was no documentation showing the required monthly 30 second test or annual 90 minute test on emergency lights within the facility.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 19.7.1.1). Findings include, but are not limited to:
1. On 2/4/2014, during record review, between 1:00 p.m. and 4:30 p.m., there were phone lists within the Disaster Plan that had staff members listed that are no longer employed with the facility. The review dates for the phone lists were not current for Accounting, Volunteers, Case Management, Human Resources, Education and Medical Records.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 2/4/2014, during record review between, 1:00 p.m. and 4:30 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as type of simulated fire, number of simulated occupants evacuated and time of simulated patient evacuation. Fire Drills in May 2013 were completed as "Coded Announcement" drills after 6:00 a.m. Facility was also missing 1st Quarter Day Shift Drill in 2013.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 2/4/2014, at 4:30 p.m., there were fire alarm notification devices within the OR #1, OR #2, OR #3, OR #4, OR #5 and OR #6 which are prohibited in patient treatment/care areas per NFPA 72 for "private mode" systems.
2. On 2/5/2014, at 9:00 a.m. there were fire alarm notification devices within patient treatment/care areas in Unit B, Unit C, ICU, Diagnostic Imaging, Emergency Department Exam Rooms and Day Surgery which are prohibited in patient treatment/care areas per NFPA 72 for "private mode" systems.
3. On 2/5/2014, at 10:46 a.m., there were missing notification devices outside the doors leading to the chiller room.

Based on record review and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff that the facility failed to test and maintain fire alarm in accordance with NFPA 72 for the entire building. 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 2/4/2014, during record review, between 1:00 p.m. and 4:30 p.m., monthly and quarterly maintenance/testing was being performed by staff and there was no documentation showing technician competence and testing and maintenance documentation was incomplete, missing information on testing and maintenance that was performed in maintaining the fire alarm system.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 19.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. On 2/5/2014, at 10:03 a.m., there was missing sprinkler coverage in oversized skylight pockets (exceeding 32 sq. ft.) in Patient Rm. A-224 and at Unit A Patio area.
2. On 2/5/2014, between 10:54 a.m. and 11:05 a.m., there were dry sprinkler system air compressors that did not have a locks on the on/off switches for the Emergency Department system, North Addition system and Imaging system.
3. On 2/5/2014, between 11:38 a.m. and 2:37 p.m., there were missing escutcheon rings on sprinkler heads in the following location but not limited to Hallway outside of PACU, Patient Rm. A, Walk in Freezer in Kitchen and adjacent to IT.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 2/4/2014, during record review, between 1:00 p.m. and 4:30 p.m., weekly, monthly and quarterly testing/maintenance was being performed by staff and there was no documentation showing technician competence and testing and maintenance documentation was incomplete, missing information on testing and maintenance that was performed in maintaining the sprinklers. Staff did not have access to the adopted 1998 edition of NFPA 25 standards and there was no record of the required 5yr. IIIC test on the fire sprinkler system.
2. On 2/5/2014, at 10:00 a.m., there was combustible storage consisting of couch cushions stacked within 18" of the sprinkler heads in Family Birth Center Storeroom A-221.
3. On 2/5/2014, at 10:46 a.m., there were gauges on the fire sprinkler riser in the Lower Mechanical Room that were dated 1984 and 2007 and were past due for replacement or recalibration since 1989 and 2012.
4. On 2/5/2014, at 10:50 a.m., there were missing spare sidewall sprinkler heads within the spare sprinkler cabinet at the Lower Mechanical Room.
5. On 2/5/2014, at 10:52 a.m. and 11:05 a.m., there was missing signage (Sprinkler Riser Room) on the doors leading to sprinkler riser in the following areas: Lower Mechanical Room wet/dry system, Emergency Department dry system, North Addition dry system and Imaging dry system.
6. On 2/5/2014, at 10:54 a.m., there were gauges on the dry fire sprinkler riser outside of the Emergency Department that were dated 2007 and 2008 and were past due for replacement of recalibration since 2012 and 2013.
7. On 2/5/2014, at 10:54 a.m., there was missing signage (6" FDC letters; white on red or red on white and what the FDC serves) on the Fire Department Connection adjacent to the Emergency Department.
8. On 2/5/2014, at 11:00 a.m., there were gauges on the dry fire sprinkler riser in the North Addition that were dated 1998 and were past due for replacement of recalibration since 2003.

Based on record review and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 2/4/2014, during record review between, 1:00 p.m. and 4:30 p.m., the facility had not conducted the required annual forward flow test of the sprinkler system, there was no record on when the last test was performed.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff that the facility failed to maintain fire extinguishers in accordance with adopted standards for all extinguishers of the facility. 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). Findings include, but are not limited to:
1. On 2/4/2014, during record review, between 1:00 p.m. and 4:30 p.m., monthly inspections were being performed by staff and staff did not have access to the adopted 1998 edition of NFPA 10 standards.
2. On 2/5/2014, at 2:00 p.m., there was not a minimum sized 10A 120B fire extinguisher located adjacent to the facilities Helicopter Pad only a 2A 10B:C.

Based on record review and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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). Findings include, but are not limited to:
1. On 2/4/2014, during record review, between 1:00 p.m. and 4:30 p.m., the facility had not conducted the required semi-annual kitchen hood/suppression inspection. Testing and maintenance inspections for the kitchen hood were completed on 2/18/2013.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff that the facility failed to prohibit the use of portable space heating devices. This resulted in the potential for ignition of nearby combustibles (LSC 19.7.8). Findings include, but are not limited to:
1. On 2/5/2014, between 9:11 a.m. and 11:10 a.m., there were portable space heaters in use within patient sleeping areas in the following locations but not limited to, Unit B Nurse Managers Office, ED Triage Area and C181 Area.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff that the facility failed to ensure that no furnishings or decorations of highly flammable character are used, unless in limited quantities or flame retardant. This resulted in the potential for excessive fire spread (LSC 19.7.5.4). Findings include, but are not limited to:
1. On 2/5/2014, at 9:17 a.m., there were combustible decorations (quilts) within the Infection Control Office that was not treated with flame retardant materials.

Based on observations and interviews it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 2/5/2014, at 11:17 a.m., there was an oxygen storage room adjacent to Respiratory Therapy that had electrical outlets and switches within 60" of the finished floor.
2. On 2/5/2014, at 2:00 p.m., there was an Medical Gas Storage Room B-104 that had electrical outlets and switches within 60" of the finished floor.

Based on record review and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1. This resulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to:
1. On 2/4/2014, during record review, between 1:00 p.m. and 4:30 p.m., the humidity policy dated 4/2011 that was presented to the surveyor did not specify the adopted humidity range. The policy only mentioned that "CDC Guidelines for Hospitals is reviewed for standards on HVAC, lighting and humidity". The 4/2011 policy did not have recommendations or procedures on what needs to be accomplished when the humidity was not within the adopted/specified range. Humidity levels were measured under the ASHRAE Standard 170 adopted 20% on the following days in the following areas: OR #5 1/31/2014, 2/1-5/2014; OR #6 1/31/2014, 2/1-5/2014; OB 1/4-7/2013, 1/10-15/2013, 1/16-24/2013, 1/27-28/2013, 2/2-3/2013, 2/8/2013, 2/10/2013, 2/14-16/2013, 2/18/2013, 2/22/2013, 2/23-24/2013, 2/26-28/2013, 3/6/2013, 3/11/2013, 3/15/2013, 3/17-27/2013, 4/12/2013, 4/16-18/2013, 4/22-24/2013, 4/27/2013, 4/29-30/2013, 5/2/2013, 5/14-15/2013, 10/29-31/2013, 11/3-4/2013, 11/20-30/2013. 12/3-19/2013, 12/21-24/2013, 12/25-30/2013, 1/31/2014 and 2/1-5/2014. Humidity Records for OR #1-#6 were not available for review for all of 2013, facility switched record programs and data was not archived as mentioned by the Facility Engineer and Maintenance Staff.

Based on record review and interviews it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 2/4/2014, during record review, between 1:00 p.m. and 4:30 p.m., monthly maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the generator and staff did not have access to the 1999 edition NFPA 110 standards. Documentation presented to the surveyor showed a 4hr. load bank test completed on 6/12/2007 which was over due since 6/12/2010 . Other facility documentation showed only a 2hr. load bank test performed 6/2011 and 6/2010 and not the required 3yr. 4hr. 80% load bank test.

Based on record review and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff that the facility failed to provide an alternate source of power in accordance with NFPA 99 3.6, for lighting at the generator and generator transfer switch which would provide a minimum of 90 minutes of power in an outage. This resulted in the potential for panic and confusion for staff and patients in a power outage. Findings include, but are not limited to:
1. On 2/4/2014, during record review, between 1:00 p.m. and 4:30 p.m., there was no documentation showing the required monthly 30 second test or annual 90 minute test on emergency lights within the generator enclosure or generator transfer switch.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Engineer and Maintenance Staff 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 2/4/2014, at 4:32 p.m., there was a non-patient relocatable power tap (RPT) within OR #1.
2. On 2/4/2014, at 4:46 p.m., there was an extension cord in use within the C-Section Room.
3. On 2/5/2014, between 9:26 a.m. and 2:38 p.m., there were relocatable power taps and extension cords in use or daisy chained together within the following areas but not limited to the Sleep Lab Control Room, Emergency ROM Triage C-179, Material Services B-122, South Dietary Office and IT Office.
4. On 2/5/2014, at 11:00 a.m., there were residential heating/cooking appliances in use in the Emergency Department Employee break room and PACU Employee break room.
5. On 2/5/2014, at 11:15 a.m., there were non-patient relocatable power taps (RPTs) in the following areas but not limited to, Emergency Triage C-179 and ED Nurse Station.