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Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to properly separate sections of health care facilities. This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 18.1.2.3, 18.1.1.4, 18.1.2.3). Findings include, but are not limited to:
1. On 01/30/2013 at 7:17 a.m., there were exposed screws and the wall was not completed at 3W008.
2. On 01/30/2013 at 7:20 a.m., the two-hour fire wall was not completed at 3N002.
3. On 01/30/2013 at 7:44 a.m., there were exposed screws and sheetrock tape on fire wall at 2W016.
4. On 01/30/2013 at 7:44 a.m., there was unfinished fire wall at staff lounge near 2W016.
5. On 01/30/2013 at 7:56 a.m., there were exposed screws, sheetrock tape above 2W001.14.
6. On 01/30/2013 at 8:05 a.m., there were ceiling penetrations and a ¼ inch space around conduit above 2W022.
7. On 01/30/2013 at 9:34 a.m., there was an unoccupied room opening into the stairwell at 2SW4.
8. On 01/30/2013 at 10:00 a.m., there were cupboards, car seats, linen, cribs, TVs, chairs, equipment, beds, portable generators, gas cylinders, and carts being stored in the 4th floor shell space that had not been approved as a storage room.
9. On 01/30/2013 at 11:15 a.m., there was a 1 inch unsealed penetration in the soda closet of the 1st floor cafeteria kitchen.
10. On 01/30/2013 at 2:07 p.m., there was a 3 inch hole in the ceiling tile near GW021.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to maintain the integrity of smoke and fire separations. 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 01/30/2013 at 11:15 a.m., there was a 1 inch unsealed penetration in the soda closet of the 1st floor cafeteria kitchen.

2. On 1/30/2013 11:04 a.m., there was a missing ceiling tile in kitchen 1H111.

Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to maintain exit corridor doors resist the passage of smoke into the means of egress in the event of a hostile fire event (LSC 18.2.3.5, Table 18.3.2.1, 18.3.6.3, Exception 2; A18.3.6.3.3). Findings include, but are not limited to:
1. On 1/30/2013 at 7:46 a.m., excessive gap at floor of fire door 2W018.
2. On 1/30/2013 at 8:08 a.m., cart blocking door from closing at 2W023.
3. On 1/30/2013 at 1:14 p.m., doors on ground level in 2 hour exit passage next to GSW01 did not latch.
4. On 1/31/2013 at 9:07 a.m., door for BW013A only had a lock, no handle and the room had over 600 amp.
5. On 1/29/2013 at 2:50 p.m., drop down near 3H303 last tested May 2011 and not annually.
6. On 1/29/2013 at 2:00 p.m., there was no monthly door inspections conducted by the facility, the inspections were conducted only quarterly per the Director of Facility Services.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to install proper hold-open devices that will release on the actuation of the fire alarm or fire sprinkler system. This resulted in the potential for smoke and fire to spread to other areas of the facility (LSC 19.2.2.3). Findings include, but are not limited to:
1. On 1/30/2013 at 11:07 a.m., door to cashier office 181, door 123, door G385 were propped open.
2. On 1/31/2013 at 7:48 a.m., wood door chalk propped open fire door G270A.
3. On 1/30/2013 at 7:20 am, the 90-minute fire door was propped open at 3N002.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services 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 01/30/2013 at 7:30 a.m., there were no signs or indicaters in 3N stairwell showing exit direction.
2. On 01/31/2013 at 9:47 a.m., there was no sign on SW5 door stating it is not an exit.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to provide a one-hour separation between hazardous areas and the corridor/ hallway. 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 1/29/2013 at 1:41 p.m., room 4204 on the 4th floor is being used to store a couch, beds, chairs, tables and no closer was installed on the door.
2. On 1/29/2013 at 1:38 p.m., the closer was removed and there was no latching hardware on door to room 4C19 on the 4th floor.
3. On 1/29/2013 at 2:21 p.m., door 3-S21 was not auto latching.
4. On 1/31/2013 at 8:00 a.m., the door was removed from storage room D in surgery area corridor near ORs.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to install vertical exit components that are constructed in accordance with approved standards. This resulted in the potential for the spread of fire/smoke vertically in new (Ch. 18) multi-story facilities 1 hour rating up to 3 stories, 2 hour rating exceeding 3 stories and existing (Ch. 19) multi-story facilities with a 1 hour rating. (LSC 8.2.5.2, 19.3.1.1). Findings include, but are not limited to:
1. On 01/30/2013 at 1:14 p.m., there was a phone and ABHR dispenser on the wall of the 2 hour exit passage way at the North stairwell first floor.

2. On 01/30/2013 at 1:11 p.m., at G164 there was an unoccupied room open to the stairwell being used for computer equipment storage.

Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services 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 patients & staff during emergency evacuation conditions (LSC 19/18.2.8). Findings include, but are not limited to:
1. On 1/30/2013 at 10:39 a.m., there were single bulb fixtures at door to outside at 1SW, GW045, & at southeast door of ED.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services 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 residents & staff during emergency evacuation conditions (LSC 19/18.2.8). Findings include, but are not limited to:

1. On 1/31/2013 at 10:42 a.m., there was no emergency lighting in the room next to 1073.

Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Director of Facility Services 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 20.7.1.1). Findings include, but are not limited to:
1. On 1/31/2013 at 10:34 a.m., there was no facility specific disaster plan available for staff at the nurse's station.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to provide fire drills and in-service training 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 1/28/2013 at 1:44 p.m. staff at switchboard were interviewed and stated it was only their second day and the facility was unable to find training documents for the staff member.
2. On 1/28/2013, during the facility record review between 10:15 a.m. & 6:00 p.m. the noc shift 1st 1/4 2012 was missing, forms were incomplete, staff response was delayed or not at all due to decibel level of horns installed throughout, making code red pages intelligible as noted on the 4/30/12 @ 11p.m. fire drill and the 10/5/12 @ 10:10 a.m. fire drill reports. Facility was counting actual fires and false alarms as fire drills. The swing shift 2012 fire drills were not staggered throughout the shift as required.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services 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 18.3.4, 9.6). Findings include, but are not limited to:
1. On 1/29/2013 at 2:10 p.m., there were three notification devices in patient treatment areas in Physical Therapy room 4H416.
2. On 1/29/2013 at 2:12 p.m., pull station obstructed by counter in room 4H416.
3. On 1/29/2013 at 2:13 p.m., strobe in patient restroom 4H417 & 4H418 in the Physical Therapy room.
4. On 1/29/2013 at 2:35 p.m., there was a strobe in 3rd floor staff room 3H300 rather than a chime strobe.
5. On 1/29/2013 at 2:50 p.m., horn/strobe in stairwell 3H.
6. On 1/30/2013 at 10:30 a.m., blocked pull station by plants in the front lobby of ABHD cardio.
7. On 1/30/2013 at 11:16 a.m., blocked pull station in the cafeteria 1st floor by table and chairs.
8. On 1/30/2013 at 1:18 p.m., blocked pull station at ED entrance by wheelchairs.
9. On 1/30/2013 at 2:00 p.m., only two out of four exits from ED had pull stations and a pull station was not located at the nurse station.
10. On 1/30/2013 at 3:09 p.m., strobes in patient areas GH15, G158, GH75, patient restroom GH19, strobe in patient treatment room GH18.
11. On 1/30/2013 at 3:24 p.m., blocked pull station near GH13.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services 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 1/28/2013 during record review between 10:30 a.m. & 6:00 p.m., there was no documentation of weekly, monthly, 1/4ly testing, and annual inspections conducted 9/22/11 and 11/20/12 were more than 12 months apart.
2. On 1/30/2013 at 10:30 a.m., the infectious control cart was blocking the pull station in the front lobby.
3. On 1/30/2013 at 11:16 a.m., the fire alarm pull station in the cafeteria was blocked by a table and chairs .
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services 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 18.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. On 1/30/2013 at 10:30 a.m., there were combustibles stored under the non-sprinklered overhang at the front entrance. Plants, trash cans, bicycles, benches, newspaper boxes.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services 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 1/29/2013 at 2:11 p.m., leaking sprinkler head in Physical Therapy room 4H421.
2. On 1/29/2013 at 2:39 p.m., corroded and leaking sprinkler head in room 3H315.
3. On 1/29/2013 at 2:46 p.m., corroded and leaking sprinkler head in room 3H334.
4. On 1/29/2013 at 2:46 p.m., corroded and leaking sprinkler head in room 3H336.
5. On 1/29/2013 at 2:47 p.m., multiple corroded and leaking sprinkler heads throughout 3rd floor cardiovascular unit.
6. On 1/30/2013 at 10:12 a.m., corroded sprinkler head in 2H202.
7. On 1/30/2013 at 10:23 a.m., corroded sprinkler head in the lobby of the Ralph Hull Regional Heart Center.
8. On 1/30/2013 at 10:25 a.m., leaking/wet sprinkler head in 2H215.
9. On 1/30/2013 at 10:33 a.m., covered sprinkler heads had sheetrock mud on the covers in the Chapel.
10. On 1/30/2013 at 10:48 a.m., loose escutcheon plate on sprinkler head in conference room 1026 in Medical Education.
11. On 1/30/2013 at 10:51 a.m., expired gauge in sprinkler room 197.
12. On 1/30/2013 at 10:57 a.m., 2 leaking sprinkler heads in the library.
13. On 1/30/2013 at 11:01 a.m., corroded green sprinkler head in conference room 1H115B.
14. On 1/30/2013 at 11:03 a.m., 2 green, corroded sprinkler heads in kitchen 1H111.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services 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 1/28/2013 during record review between 10:15 a.m. & 6:00 p.m., the previous annual forward flow test was conducted on 1/19/2012 and was past due on the date of the survey.

Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to maintain fire extinguishers in accordance with adopted standards. This resulted in the potential for fires to progress beyond incipient stage (LSC 18.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:
1. On 1/29/2013 at 2:10 p.m., fire extinguisher obstructed in Physical Therapy room 4H416.
2. On 1/30/2013 at 8:40 a.m., fire extinguisher 2FEX07 and 2FEX04 past due for 6-year hydro test.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to maintain kitchen hood and duct systems. This resulted in the potential for fire spread due to inadequate maintenance of equipment. Findings include, but are not limited to:

1. On 1/30/2013 at 11:15 a.m., 4 inch gap in the filters of the hood in the cafeteria on the 1st floor.
2. On 1/30/2013 at 11:15 a.m., when the filters where removed, grease spilled onto the floor because they were full.
3. On 1/30/2013 at 11:15 a.m., cafeteria staff stated they wipe the filters down weekly.
4. On 1/30/2013 at 11:16 a.m., filter not draining into drip catch for the hood in the 1st floor cafeteria.
5. On 1/30/2013 at 1:40 p.m., per Head Chef for all of the Kitchens, a third party vendor comes to clean the hoods every six months and had cleaned the hood the day before.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services 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 01/29/2013 at 2:44 p.m., space heaters in rooms 3H326 & room 3H327 were not properly listed.
Surveyor was accompanied by the Director of Facility Services who acknowledged these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" from 40" up to 80" above the floor and no projections exceeding 4 1/2" below 40" from the floor. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10, S&C). Findings include, but are not limited to:
1. On 1/29/2013 at 2:35 p.m., a foam based tree and chairs were in the corridor near 3H300.
2. On 1/29/2013 at 2:36 p.m., chairs and water cooler in corridor near 3H305.
3. On 1/30/2013 at 12:49 p.m. foam based plant in corridor across from elevator H.
4. On 1/30/2013 at 2:37 p.m., linen cart in corridor next to G528 near ED.
5. On 1/30/2013 at 2:37 p.m., linen carts, chairs, and carts in corridor across from G520.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services 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 19/18.7.5.4). Findings include, but are not limited to:


1. On 1/31/2013 at 10:31 a.m., there were soiled linen carts open to the corridor located near the men and womens dressing rooms.

Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to ensure that no storage of highly flammable character existed in the corridors. This resulted in the potential for excessive fire spread (LSC 19.7.5.5, Exhibit 19.23). Findings include, but are not limited to:
1. On 1/31/2013 at 8:14 a.m., there was a 60 gallon trash container and soiled linen container in hallway across from OR 5.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to provide safe storage for compressed gas cylinders. This resulted in the potential for injury to staff and patients from a damaged compressed gas cylinder releasing unexpectedly. (LSC 19.3.2.4, 4.3.1.1.2). Findings include, but are not limited to:
1. On 01/29/13 at 7:14 a.m., there was an unsecured gas cylinder, only one chain in Endo 1 & Endo 2, G-355 & BW011.
2. On 1/30/2013 at 8:48 a.m., unsecured CO2 cylinders, only one chain for the soda machine in the Service Level Kitchen.
Based on observations, record review and interviews it was determined through on-going dialog with the Director of Facility Services 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 19/18.3.2.4, 4.3.1.1.2). Findings include, but are not limited to:
3. On 01/29/13 at 3:15 p.m., there was Oxygen storage in Clean Utility room 3C006, BW011, 4S20 and electrical outlets were not 60 inch above floor.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to ensure piped in medical gases comply with NFPA 99. This resulted in the potential for injury to patients during medical procedures. Findings include but are not limited to:
1. On 01/29/13 at 7:07 a.m., medical gas panel blocked by carts at OR 9.
2. On 1/29/13 at 2:00 p.m., there was no annual med gas certification, no outlet testing reports.
3. On 1/30/13 at 10:30 a.m., there was no check valve installed between the main and secondary bulk oxygen storage tanks per the 2011 inspection report from Praxair.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services 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:
1. On 1/28/2013 during record review between 10:15 a.m. & 6:00 p.m., the facility policy stated that humidity levels should be between 20%-60% which did not meet the ASHRAE Standard 170 requirements of 30-60%. The policy stated if out of range, it was up to the practitioner to decide if the procedure occurred or not. Humidity levels were measured under 30% on the following days: OR1: 10/5, 11/22, 11/26, 12/28 through date of survey; OR2: 10/5; OR3: 9/15, 10/5; OR4: 9/14, 10/4-10/6, 12/22; OR5: 9/3, 9/12-9/15, 10/3-10/6, 12/22; OR6: 9/13, 10/2-10/5, 11/26-11/27, 12/16; OR7: 9/11-9/13, 9/26, 10/4-10/9, 10/22, 12/16; OR8: 9/14, 10/4-10/5 OR9: 9/13, 10/3-10/7; OR9: 9/13, 10/3-10/7
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to provide fire drills and in-service training 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 1/28/2013 at 1:44 p.m. staff at switchboard were interviewed and stated it was only their second day and the facility was unable to find training documents for the staff member.

Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with the Director of Facility Services 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 1/28/2013 during record review between 10:15 a.m. & 6:00 p.m., there was no monthly, no tech competence, no weekly water level checks/ monthly specific gravity level checks documented.

2. On 1/30/13 at 4:30 a.m., emergency shut off switches for the three generators were located inside of the generator enclosure.

3. On 1/31/2013 at 9:05 a.m., there was no battery powered emergency light at the panel in BW013, and there was no battery powered task illumination at the generator and transfer switch locations for troubleshooting at three generators.

Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services 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 patients & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:
1. On 01/29/2013 during the tour between 7:00 a.m. & 3:30 p.m., the following electrical deficiencies were found: 1) missing screw on outlet on ceiling in OR 1; 2) non-patient power strip on floor at warmer in C-Section OR, 3) non-patient power strip on floor Endo 1 & 2; 4) four outlet pull down on the floor in OR 4; 5) power strip permanently attached in 4314 & 4315; 6) non-patient power strip at nurse station near 4308; 7) two power strips on the floor in room 4S26; 8) non-patient power strip at nurse station near 4306 & 4307; 9) non-patient power strip at nurse station near 4307; 10) power strip on floor in 4S20; 11) non-patient power strip 4C37; 12) non-patient power strip at nurse station 4th floor center; 13) two non-patient power strips in office 4C20; 14) non-patient power strip plugged into patient power strip on Opix cart at 4100, 4101, 4102, 4103, 4106; 15) non-GFCI outlet in 4014 within 5 feet of mop basin;16) power strip on floor with no hospital sticker on it showing it had been checked by facility in room 4N15; 17) two power strips on daisy chained on floor of office 4104; 18) non GFCI outlet in 3-S15 near the mop basin; 19) on the floor in control station 3300; 20) two power strips on the floor in room 3304; 21) two power strips on the floor in room 3312; 22) power strips daisy chained in 3-C16.
. Director of Facility Services indicated that power strips were permanently attached throughout the facility.
2. On 01/29/2013 at 2:25 p.m. transformer was under sized, warm to the touch, and discoloring for infrared light in Sleep Lab room near control station 3300, in Sleep Lab 3303, in Sleep Lab 3306, in Sleep Lab room 3307.
3. On 01/30/2013 during the tour between 7:00 a.m. & 3:30 p.m., the following electrical deficiencies were found: 1) there was a non-patient power strip on a cart in 3W014; 2) non-patient power strip on floor at nurse station 3rd floor west; 3) non-patient power strip at charting station 4876 across from nurse station; 4) household microwave in 3W012; 5) non-patient power strip at charting station near 3101; 6) power strip on the floor of 3N002; 7) household microwave in 3N20; 8) household microwave plugged into power strip on the floor in the staff lounge near 2W016; 9) household toaster oven in staff lounge near 2W016; 10) non-patient powers strip at charting station 2682; 11) non-patient power strip at nurse station for the ICU near 2005; 12) non-patient power strip at charting station 2673 for 2005/2006; 13) non-patient power strip at the computer in room 2005; 14) non-patient power strip at computer for charting station of rooms 2007 & 2008; 15) non-patient power strip in room 2008; 16) power strip on floor of office 2W036; 17) non GFCI outlet at mop basin in 2023; 18) household coffee maker in 2S22; 19) household microwave in 2414; 20) microwave plugged into power strip in staff lounge 2416; 21) listed space heater without 3 foot clearance in Chaplin Services office; 22) power strip on floor with small refrigerator plugged into it in the Chaplin Services office; 23) power strip with extension cord plugged into it in the medical records office; 24) household microwave in Nurse Supervisor and scheduling room 1020; 25) power strips on the floor throughout Medical Education room 1024; 26) non-listed space heater in office 1025 of Medical Education room; 27) power strip on the floor of admitting room 186; 28) power strip hanging by the cord in the library office; 29) power strip daisy chained in the library office; 30) power strip on the floor of the cashier office 181; 31) power strip on the floor in 1N029; 32) household microwave in the physician lounge 1N001B; 33) household microwave and toaster in 1N009; 34) power strip on the floor of 1N017; 35) coffee maker, microwave, and refrigerator plugged into power strip in 1N017; 36) household coffee maker, microwave, and refrigerator in 1N017; 37) household toaster oven, microwave, and coffee maker in 1W001B; 38) power strips throughout the President office 1W020B; 39) household coffee maker in G508; 40) non-patient power strip in G507; 41) non-patient power strips in GW002, GW012, GW014; 42) 2 non-patient power strips in GW003; 43) power strips on the floor of GSDR023; 44) there was a household microwave and coffee maker in G348; 45; power strips on counters of Lab; 46) household microwave and coffee maker in G-348; 47) power strips on the floor in G-355; 48) wire mold too low on the counters across from sample storage fridge next to G-355; 49) wire mold too low throughout the Lab; 50) power strips on the floor and counters throughout the Lab; 51) 3 power strips daisy chained in G-363; 52) microwave plugged into an extension cord in G389; 53) 2 non-patient power strips in Cath Lab 3; 54) 3 non-patient power strips in Cath Lab 2; 55) power strip hanging from wall with extension cord plugged into it in G379; 56) household microwave in G229; 57; 57) 2 non-patient power strips on the floor of GH15; 58) refrigerator plugged into power strip in GH13; 59) 4 power strips on the floor in G14A; 60) household microwave in G272; 61) permanently attached power strip without covers at station 5 & 6 plugged into wire mold not the wall in Post/Pre OR; 62) non-patient power strip on counter across from the staff lounge in short stay; 63) non-patient power strip on the floor under desk near G270B; 64) open junction box short stay near the nurse station; 65) power strip hanging by the cord in storage room D in surgery; 66) power strip on the floor for a battery charger in the Decontamination room near ORs; 67) non-patient power strip in the Endo nurse station; 68) non-patient power strip near G404 in Endo; 69) yellow extension cord by fire extinguisher in Sterile Processing room; 70) electrical outlet box loose in the far right corner wall of Sterile Processing room; 71) power strip on the floor right corner of the Sterile Processing room; 72) blocked electrical panel by B028 in the Service level Kitchen. 73) UL60601-1 Tripp Lite had a replaced cord end in room 3203; 74) UL60601-1 Tripp Lite had a replace cord end in room 2103, 3016, & in Recovery
Maintenance Staff indicated, after speaking with Tripp Lite, the power strips that have had the ends removed are no longer up to code and will need to be replaced.
4. On 01/31/2013 during the tour between 3:00 a.m. & 12:30 p.m., the following electrical deficiencies were found: multiple blocked electrical panels in the Kitchen on the Service Level; open junction box inside B072 above old critical care; refrigerator plugged into power strip in outer room of B105; non-listed power strip in B105A; broker cord plugged into power strip in B083; 6 to 2 plug adaptor with microwave, refrigerator, coffee makers, and toaster plugged into it in the boiler room; daisy chained power strips in the phone room upper office of B066; exposed wires under the wall cabinets in the linen holding room B064
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on the observations and interview during the survey, it was determined through on-going dialog with the Director of Facility Services 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 19.2.3.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623). Findings include, but are not limited to:
1. On 01/29/2013 at 1:07 p.m. ABHR above light switch in room 2201, 2202, & 4309.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.