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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 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 19.1.2.3, 19.1.1.4, 19.1.2.3). Findings include, but are not limited to:
1. On 1/30/2013 at 6:41 a.m., above door 3SDR6 there was exposed sheetrock tape, screws, gypsum wall board at the corner was not completed, and the right side was not taped above the door.
2. On 01/30/2013 at 6:52 a.m., there were exposed screws and sheetrock tape on elevator shaft at 3SDR5 next to staff elevator 3.
3. On 01/30/2013 at 7:48 a.m., there was sheetrock unfinished, not taped, five unsealed 2 inch penetrations, and one of the walls was not full height above the video camera at 2SDR6.
4. On 01/30/2013 at 7:53 a.m., there was only a single layer of sheetrock above 2SDR7.
5. On 01/30/2013 at 7:55 a.m., there were exposed screws, sheetrock tape, and unapproved patches on fire wall at 2SDR7.
6. On 01/30/2013 at 9:48 a.m., the fire wall was not completed at the room in the office of 4C20.
7. On 01/30/2013 at 9:59 a.m., the fire wall was not completed at the other side of corridor next to 4C20.
8. On 1/31/2013 at 8:11 a.m., there were two storage rooms near the ORs that were over 100 square feet and not separated from the suite by a 1 hour separation in room G121.
9. On 1/29/2013 at 2:00 p.m., the life safety drawings did not match actual buildings or as built construction documents.
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 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 01/29/2013 at 12:59 p.m., there were two unsealed 2 inch penetrations above door 4S16.
2. On 01/29/2013 at 3:10 p.m., five 1 inch unsealed penetrations were found at 3C18.
3. On 01/30/2013 at 7:17 a.m., there were exposed screws and the wall was not complete at 3W008.
4. On 1/29/2013 at 2:22 p.m., there were gaps around sprinkler heads in 3-S20 and 3-S15.
5. On 1/29/2013 at 2:30 p.m., there was a loose escutcheon ring and a gap around the sprinkler head in the restroom of room 3311.
6. On 1/29/2013 at 2:53 p.m., the escutcheon ring was missing in 3526.
7. On 1/29/2013 at 3:08 p.m., there was a loose escutcheon ring in the restroom of room 3201, 2305, conference room 1026 in Medical Education, in changing rooms 2, 3, and 4 for X-Ray 4/5.
8. On 1/30/2013 at 3:24 p.m., there was a missing escutcheon ring on sprinkler head in GH15.
9. On 1/31/2013 at 8:34 a.m., there was a dropped escutcheon ring in B081A, 2 dropped escutcheon rings in Room A of Sterile Processing, there were 2 escutcheon rings loose in Service Level Kitchen.
10. On 1/30/2013 8:20 a.m., there was a ¼ gap around sprinkler head in the restroom of room 2006 and the escutcheon plate was too small.
11. On 01/30/2013 at 7:48 a.m., there was a ½ inch unsealed penetration near 2SDR6.
12. On 01/30/2013 at 7:56 a.m., there were exposed screws and sheetrock tape above 2W001.14.
13. On 01/30/2013 at 8:05 a.m., there were ceiling penetrations and a ¼ inch space around conduit above 2W022.
14. On 01/30/2013 at 8:59 a.m., there were at least 5 penetrations in electrical room 2N8.
15. On 01/30/2013 at 9:34 a.m., there was an unoccupied room opening into the stairwell at 2SW4.
16. On 01/30/2013 at 2:07 p.m., there was a 3 inch hole in the ceiling tile near GW021.
17. On 01/30/2013 at 2:53 p.m., there were two 3 inch unsealed penetrations in G369A.
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 maintain exit corridor doors resist the passage of smoke into the means of egress in the event of a hostile fire event (LSC 19.2.3.5, Table 19.3.2.1, 19.3.6.3, Exception 2; A19.3.6.3.3). Findings include, but are not limited to:
1. On 1/29/13 at 1:19 p.m., there were roller latches on doors of linen closet 4S21.
2. On 1/31/2013 at 8:11 a.m., removed door for storage room G121 near ORs.
3. 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.
4. On 1/29/13 at 1:49 p.m., 1 ¼ inch undercut on the door to 4th floor 4103.
5. On 1/31/2013 at 8:09 a.m., door not latching adjacent to G105 and G102.
6. On 1/30/2013 at 9:12 a.m., roller latches on the doors for 2S21.
7. On 1/30/2013 at 9:25 a.m., roller latches on the doors for 2422.
8. On 1/30/2013 at 9:41 a.m., the door for 2444 does not latch.
9. On 1/30/2013 at 1:14 p.m., doors on ground level in 2 hour exit passage next to GSW01 do not latch.
10. On 1/30/2013 at 3:07 p.m., roller latches on the doors for G162.
11. On 1/30/2013 at 3:18 p.m., gap in top left corner of the door frame for G212.
12. On 1/31/2013 at 7:51 a.m., roller latches on door G264B in OR.
13. On 1/30/2013 at 7:20 a.m., drop prop being used at 3N002 a 90 minute fire door.
14.On 1/29/2013 at 1:11 pm, the corridor doors at elevator #4 4SDR2 were not closing.
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 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 1/29/2013 at 7:00 a.m., the emergency lights were plugged into wall in OR 1, OR 2.
2. On 1/29/2013 at 7:03 a.m., emergency light not hardwired and too low in OR 3, OR 4, & OR 6.
3. On 1/30/2013 at 3:00 p.m., there was no emergency light in Cath Lab 2.
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 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 install fire alarm system in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 19.3.4, 9.6). Findings include, but are not limited to:
1. On 1/29/2013 at 12:56 p.m., there was a horn/strobe in stairwell 3 of the 4th floor, and 3rd floor, and 3SW2, 3N, 2SW2 of the 2nd floor, 2SWS of the 2nd floor, and throughout facility stairwells per Director of Facility Services.
2. On 1/29/2013 at 1:29 p.m., there were no chime strobes in 4th floor staff room 4C27, 4C28, 4C29, 4C23, 3312, 3314.
3. On 1/30/2013 at 6:48 a.m., there was no pull station at the 3rd floor west nurse station, no pull station at nurse station for ICU near room 2005, pull station obstructed at nurse station ICU North, blocked pull station at the nurse station 2SW, blocked pull station B128 by a chair, pull station blocked by printer and computer monitor in the Recovery room, pull station blocked by carts at nurse station short stay adjacent to G019, pull station blocked at nurse station across from G600B,
4. On 1/31/2013 at 7:50 a.m., there were strobes in patient restrooms G262, G245, G401G, & G403.
5. On 1/31/2013 at 9:53 a.m., there were no refrigerant leak detection alarms at the entrances for B043 chiller room.
6. On 1/29/2013 at 1:53 p.m., there was a battery powered smoke detector not wired into the fire alarm system in 4N15.
7. On 1/31/2013 at 8:08 a.m. there was no smoke detector within 5 feet of fire alarm panel in BW013.
8. On 1/29/2013 at 1:53 p.m., no chime/strobe in 4th floor staff room 4N15, 1N008, 1N003, 1N004, & 1N005.
9. On 1/30/2013 at 7:24 a.m. in room 310 across from elevator A, 3CL1 electrical panel breaker #12 there was no set screw.
10. On 1/30/2013 at 1:18 p.m., the pull station at ED entrance was blocked by wheelchairs.
11. 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.
12. On 1/30/2013 at 3:00 p.m., there was a notification device in Cath Lab 2 & 4, and a missing device in control room for Cath Lab 2 & 4.
13. On 1/30/2013 at 3:09 p.m., there was a strobe in patient area G158 & patient restrooms G150, G204, G151, GH18, & GH19.
14. On 1/31/2013 at 8:08 a.m. there was no smoke detector within 5 feet of fire alarm panel in BW013.
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 20.3.4, 9.6). Findings include, but are not limited to:
1. On 1/31/2013 at 10:43 a.m., there was no label on door to the fire alarm room or breaker.
2. On 1/31/2013 at 10:31 a.m., there was a strobe in the patient restroom 2204 and a strobe in X-ray room.
3. On 1/31/2013 at 10:40 a.m., there was no smoke detector within 5 feet of panel #20S1A-1, nor were the four batteries dated.
4. On 1/31/2013 at 10:40 a.m., in room 2133 there was a plastic dust cap on the smoke detector.
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 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 the facility record review between 10:15 a.m. & 6:00 p.m., there were no documentation of weekly, monthly, or quarterly testing, and the annual inspections conducted 9/22/11 and 11/20/12 were more than 12 months apart.
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 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 1/28/2013 at 11:00 a.m., there was an annual sprinkler report from Rainbow for December 2012, indicating that there was incomplete sprinkler coverage for the building and the facility had no documentation of making the corrections. The report noted the following: "a void in sprinkler coverage at the entrance to 115 A, a void in coverage at G530B and the hallway adjacent. Hallway signs affixed directly to ceiling on 1st floor blocking heads. The wash basin in the kitchen lacks one head."
2. On 1/29/2013 between 7:00 a.m. and 3:12 p.m., the following locations were found to be lacking proper sprinkler coverage or were deficiencies with the installation of the sprinkler system: there was missing or inadequate sprinkler coverage in OR 2, 3, 4, 6, 4S16, 4S24, 4C12, electrical room, near the entry door of 4H404, electrical room 3-S16, and in the showers of rooms 3207, 3208, 3209, 3206, 3202. There was an obstructed head in 3C21 first room and a missing sprinkler head in 3C21 second room. The standpipe on the roof was not labeled. The sprinkler riser gauge was not dated in the center penthouse. There were no caps on pipes in hose station cabinets near rooms 4307, 4101, & 3301.
3. On 1/30/2013 between 7:00 a.m. and 3:12 p.m., the following locations were found to be lacking proper sprinkler coverage or were deficiencies with the installation of the sprinkler system: room 2401, there was missing or inadequate sprinkler coverage in electrical room, 2205, 2204, 2C21, 2S16, far corner of 2414 and in the restroom of 2414, and in the showers of rooms 3117, 3111, 3110, 3108, 3101, 2010, 2207, 2206, 2202, 2203, 2310, 2414, 2412, 2406, 2402, and in rooms G1S69, 310 on the 3rd floor across from elevator A, back part of room G389, electrical rooms 210 and 211 across from elevator A, electrical room 1H114, there was no sprinkler coverage for the overhang covering combustibles such as wooden benches and trash cans at the main entrance 1st floor. There was one missing sprinkler head in x-ray 2. There was a permanent track blocking sprinkler head within 4 inches in room 2007. There was no cap on pipe in hose station cabinets near room 2522, near Chaplain Services office on 1st floor, next to elevator B 1st floor. room 2401 There was missing or inadequate sprinkler coverage in electrical room 2205, 2204, 2C21, 2S16, far corner of 2414 and in the restroom of 2414, and in the showers of rooms 3117, 3111, 3110, 3108, 3101, 2010, 2207, 2206, 2202, 2203, 2310, 2414, 2412, 2406, 2402, and in rooms G1S69, 310 on the 3rd floor across from elevator A, electrical rooms 210 and 211 across from elevator A, electrical room 1H114, there was no sprinkler coverage for the overhang covering combustibles such as wooden benches and trash cans at the main entrance 1st floor. There was one missing sprinkler head in x-ray 2. There was a permanent track blocking sprinkler head within 4 inches in room 2007. There was no cap on pipe in hose station cabinets near room 2522, near Chaplain Services office on 1st floor, next to elevator B 1st floor. There was no spare sidewall sprinkler heads in the sprinkler cabinet for the ED.
3. On 1/31/2013 between 7:00 a.m. and 10:00 a.m., the following locations were found to be lacking proper sprinkler coverage or were deficiencies with the installation of the sprinkler system: there was missing or inadequate sprinkler coverage in sterile processing office where a head was blocked with plastic, missing sprinkler coverage at wash area near dishwasher in kitchen on service level, B-072, at work fans in room B001, B102, alcove near stairs of SW5 service level, and under air handler exceeding 4' in SW5 on service level. There was no cap on pipe in hose station cabinets near room OR 6. The FDC at the loading dock was not marked with " FDC " signage in 6" letters red on white.
4. On 1/31/2013 at 8:54 a.m., the air compressor in the Epic training room BW023 has shut off switch installed, and the gauges were passed due for 5 year calibration or replacement.
5. On 1/31/2013 at 9:15 a.m., sprinkler protection for the chapel could not be verified.
6. On 1/31/2013 at 9:21 a.m., missing sprinkler head at B070.
7. On 1/31/2013 9:48 a.m., room off back of pharmacy was not fully sprinklered.
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 20.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. On 1/31/2013 at 10:30 a.m., there was a missing sprinkler head over the nurses station.
2. On 1/31/2013 at 10:55 a.m., there were combustibles stored under the non-sprinklered overhang in front of the ASC. Plants, trash cans, bicycles.
3. On 1/31/2013 at 10:55 a.m., there was no address on the FDC to identify which building it serviced and there was no FDC sign.
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. 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 1/31/2013 at 10:40 a.m., there were outdated gauges (2008) on the riser at the stairwell near 2133.
2. On 1/31/2013 at 10:40 a.m., there were no spare sidewall sprinkler heads at the riser near 2133.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations, record review 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. 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 01/28/2013 during record review between 10:15 a.m. & 6:00 p.m., there was no documentation for weekly or monthly testing of sprinklers. According to Director of Facility Services staff, they only do quarterly visual on sprinkler heads not monthly.
2. During the facility tour on 1/29/2013 between 7:00 a.m. & 5:30 p.m., the following deficiencies were noted with sprinkler heads: sprinkler heads had debris and were painted in OR 1; there was debris hanging from sprinkler head in OR 7; sprinkler head had sheetrock mud in C Section OR; sprinkler gauge in 4S17 4th floor soiled work room near elevator C dated 1974; obstructed sprinkler head in 4S15; painted sprinkler head in 4309; painted sprinkler head in restroom of 4309; painted sprinkler head 4S25 near Elevator #4 on the 4th floor; two painted sprinkler heads in 4S24; painted sprinkler head in restroom of room 4307; painted sprinkler head in restroom of room 4306; two painted sprinkler heads in room 4303; painted sprinkler head in room 4302; painted sprinkler head between door 4C35 and 4C34; painted sprinkler head 4C30; painted sprinkler heads throughout 4th floor center; painted sprinkler head 4C28; two painted sprinkler heads in room 4203; out dated sprinkler gauge in 4N10 Fire Sprinkler control valve; painted sprinkler head in alcove across 4N10; restroom of room 4105 missing escutcheon plates; painted sprinkler head in 4N15; painted sprinkler head in 4104; two painted sprinkler heads in 4103; painted sprinkler head in closet of 4102; sprinkler gauge in Fire Sprinkler Valve room 3-S18 is dated 1973; no cap on hose station cabinet near room 3301; & there was a dirty sprinkler head in 3208.
3. During the facility tour on 1/30/2013 between 3:00 a.m. & 4:30 p.m., the following deficiencies were noted with sprinkler heads: damaged sprinkler head in restroom of room 3016; damaged sprinkler head in 3004; painted sprinkler head 3117; corroded, painted, leaking sprinkler head in 3111; painted sprinkler head in room 3107; painted and dirt on the sprinkler head in MS2 next to elevator A on the 3rd floor; the gauge in sprinkler room 3N21 was dated 1973; red paint on sprinkler head in the 3N stairwell; painted sprinkler head at the SW1 door for stair 1 at the 2nd floor; sheetrock mud on sprinkler head in the restroom of room 2103; paint on sprinkler head in restroom of room 2102; damaged sprinkler head in restroom of 2007; paint and debris on sprinkler head in room 2207; sprinkler head in 2016 completely covered with paint and sheetrock mud; no escutcheon ring on sprinkler head in the staff lounge 2C11; painted sprinkler head in 2C21; painted sprinkler head in room 2312; dirty sprinkler head in room 2311; painted sprinkler head in restroom of room 2310; painted sprinkler head in room 2308; expired gauge in fire sprinkler room 2S18; damaged sprinkler head in the restroom of room 2302; painted sprinkler head in the restroom of room 2301; painted sprinkler head in the restroom of room 2406; dirty sprinkler head in the restroom of room 2402; corroded sprinkler head in the cashier office 181; painted sprinkler head in room 123; painted sprinkler head in soda closet of cafeteria kitchen 1st floor; gauge dated 1972 in fire sprinkler room 173; no spare sidewall sprinkler heads in the sprinkler cabinet for the ED; corroded sprinkler head G340A; dirty sprinkler heads in room G-355; 2 sprinkler gauges dated 1984 in G161; painted sprinkler head in G217B; corroded and wet sprinkler head outside of GH17; 2 corroded and wet sprinkler heads in GH17; 2 corroded and wet sprinkler heads in GH16; 2 corroded sprinkler heads in G14A; 2 corroded sprinkler heads next to GH12; & corroded sprinkler head next to GH09.
4. During the facility tour on 1/31/2013 between 6:30 a.m. & 12:30 p.m., the following deficiencies were noted with sprinkler heads: painted sprinkler head in G270A; damaged sprinkler head across from OR 3; corroded sprinkler head near dish washer in Service Level Kitchen; multiple corroded sprinkler heads in the Service Level Kitchen; sprinkler head by char broiler covered in grease in Service Level Kitchen; all sprinkler heads in Service Level Kitchen near hoods covered in grease; gauges dated 2006 in the Epic training room BW023; gauge on riser dated 1974 in storage room B074; gauge dated 1974 in B070; painted sprinkler head at electrical panel MCC-D1 in B010; painted sprinkler head north end of B010; painted sprinkler head in B091.
5. On 1/31/2013 at 7:30 a.m., the hydrant on the north side of the building near the loading dock was obstructed with vegetation and was not maintained 3' clear.
6. On 1/31/2013 at 7:40 a.m., annual fire pump test report on site was dated 8/3/2011.
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 fire extinguishers in accordance with adopted standards. 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 1/28/2013 at 2:00 p.m., the fire extinguisher WAR6 and AUM5 were listed as past due for 6 year hydrotest per the Valley report.
2. On 1/29/2013 during the facility tour between 7:00 a.m. & 5:30 p.m., the following fire extinguisher deficiencies were observed: the fire extinguisher was mounted too high in south penthouse on roof; fire extinguisher too high in 4S16; fire extinguisher too high 3-S16; & fire extinguisher obstructed near 3301.
3. On 1/30/2013 during the facility tour between 3:00 a.m. & 4:30 p.m., the following fire extinguisher deficiencies were observed: fire extinguisher too high adjacent to 2423; fire extinguisher obstructed in medical records room on the 1st floor; fire extinguisher obstructed in Lab; fire extinguisher obstructed across from G-355 in the lab; fire extinguisher obstructed in Pathology; fire extinguisher too high next to G351 in lab; & fire extinguisher too high next to G379.
4. On 1/31/2013 during the facility tour between 6:30 a.m. & 12:30 p.m., the following fire extinguisher deficiencies were observed: fire extinguisher too high in Sterile Processing room; fire extinguisher obstructed near the wash area in the Service Level Kitchen; fire extinguisher obstructed in Service Level Kitchen near the exit door; fire extinguisher obstructed by cart near the lockers in the Service Level Kitchen; 2 fire extinguishers were mounted too high in B010; no class A fire extinguisher in B105; & fire extinguisher in B-04S too high as well as too small.
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 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 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, and the hood filters and duct work were greasy on the day of the survey.
2. On 1/31/2013 at 8:40 a.m., suppression line under hood not secure and not aimed correctly above the stove in the Service Level Kitchen.
3. On 1/31/2013 at 8:40 a.m., there were 2 inch gaps in the hood filters above both of the cook tops in the Service Level Kitchen.

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 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 during the facility tour between 7:00 a.m. & 5:30 p.m., the following items were obstructing the corridor: a scale, supplies & soiled linen were stored in the corridor near 4312; charting stations near 4308 & 4310 did not automatically close; there was a vital sign cart charging in corridor near 4306; two portable charting carts charging in corridor near 4302 & one near 4105; three light fixtures extended into corridor 6.5 inches across from 4C1; two light fixtures extended into corridor 6.5 inches near room 4N110; chairs, tables, and plants in corridor outside 3308; wheelchairs in corridor near 3SW7.
2. On 1/29/2013 at 1:35 p.m., Maternity Care Coordinator office 4C20 open to corridor, missing door and partial wall only had a curtain.
3. On 1/29/2013 at 2:27 p.m., soiled linen in corridor near room 3302.
4. On 1/30/2013 during the facility tour between 3:00 a.m. & 4:30 p.m., the following items were obstructing the corridor: linen cart protruding 7 inches into the corridor across from room 3003; oxygen cylinders obstructing corridor across from nurse station in ICU near room 2007; chair at charting station reduced corridor to 7 feet across from room 2010, next to room 2202, next to room 2314, next to room 2302, next to room 2305 & next to room 2208;
5. On 1/30/2013 at 9:36 a.m., the charting station did not have an auto closure next to room 2406, and the charting station reduced corridor to less than 8 feet next to 2406.
6. On 1/30/2013 at 9:40 a.m., chairs at charting station reduced corridor to less than 8 feet near room 2401.
7. On 1/31/2013 at 8:15 a.m., storage space in Room H open to corridor across from wash sink and OR 8.
8. On 1/31/2013 at 9:12 a.m., chair at the top of the stairs for the 2 hour passageway SW8.
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 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 1/31/2013 at 10:30 a.m., there was a scale and soiled linen cart in the corridor near room 2145.
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 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 1/29/2013 at 12:57 p.m., there was a foam based plant in 4th floor lobby for elevator C.
2. On 1/29/2013 at 2:51 p.m., foam based plant near 3SW5.
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 provide safe storage for compressed gas in the oxygen storage room. This resulted in the potential for injury to staff and patients from a damaged compressed gas cylinder releasing unexpectedly. (LSC 18.3.2.4, 4.3.1.1.2). Findings include, but are not limited to:
1. On 1/30/2013 at 10:12 a.m., unsecured gas cylinders, only one chain in 2H213.
2. On 1/30/2013 at 11:15 a.m., 4 unsecured CO2 cylinders in the soda closet of the cafeteria.
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 systems 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 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 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 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 at 2:05 p.m., two power strips on the floor of 4H405, one hanging by the cord.
2. On 01/29/2013 at 2:06 p.m., non-patient power strip on the floor 4H413.
3. On 01/29/2013 at 2:06 p.m., power strip on the floor of 4H414.
4. On 01/29/2013 at 2:06 p.m., non-patient power strip on cart in 4H414.
5. On 01/29/2013 at 2:06 p.m., household coffee maker, microwave, and toaster in room 4H415.
6. On 01/29/2013 at 2:07 p.m. 4H415 had three power strips.
7. On 01/29/2013 at 2:07 p.m., non-patient power strip at printer across from 4H429.
8. On 01/29/2013 at 2:08 p.m., power strip on floor 4H429.
9. On 01/29/2013 at 2:09 p.m., extension cord and power strip on floor in board room 4H426.
10. On 01/29/2013 at 2:10 p.m., three power strips on the floor in Physical Therapy room 4H419.
11. On 01/29/2013 at 2:11 p.m., white extension cord plugged into power strip Physical Therapy room 4H420.
12. On 01/29/2013 at 2:11 p.m., two power strips on the floor in Physical Therapy room 4H420.
13. On 01/29/2013 at 2:11 p.m., two power strips on the floor in Physical Therapy room 4H421.
14. On 01/29/2013 at 2:12 p.m., power strip on floor at sink and at nurse station in the Physical Therapy room.
15. On 01/29/2013 at 2:35 p.m., two power strips on the floor of 3H300.
16. On 01/29/2013 at 2:37 p.m., power strip hanging by the cord in 3H302.
17. On 01/29/2013 at 2:37 p.m., power strip on the floor in 3H302.
18. On 01/29/2013 at 2:38 p.m., power strip on the floor at the nurse station across from 3H309.
19. On 01/29/2013 at 2:39 p.m. non-patient power strip in Exam 3H314.
20. On 01/29/2013 at 2:39 p.m., non-patient power strip on the floor of the nurse station near 3H315.
21. On 01/29/2013 at 2:40 p.m., power strip on the floor of 3H315 & 3H316.
22. On 01/29/2013 at 2:40 p.m., power strips daisy chained in 3H321.
23. On 01/29/2013 at 2:41 p.m., multiple power strips on the floor throughout the cardiovascular unit.
24. On 01/29/2013 at 2:41 p.m., household microwave, coffee maker, and toaster in 3H322.
25. On 01/29/2013 at 2:41 p.m., six to two plug adaptor in 3H322.
26. On 01/29/2013 at 2:43 p.m., multiple non-patient power strips throughout exam rooms in cardiovascular unit.
27. On 1/30/2013 at 10:15 a.m., household microwave and toaster in 2H204.
28. On 1/30/2013 at 10:23 a.m., non-patient power strip permanently attached in 2H225.
29. On 1/30/2013 at 10:24 a.m., non-patient power strip in 2H217.
30. On 1/30/2013 at 10:25 a.m., non-patient power strip in 2H215.
31. On 1/30/2013 at 1:18 p.m., non-listed space heather ED reception desk without three feet clearance.
32. On 1/30/2013 at 2:23 p.m., non-patient power strip at nurse station for ED.
33. On 1/30/2013 at 2:23 p.m., extension cord in GW009.
34. On 1/30/2013 at 2:24 p.m., household microwave, toaster, coffee pot in GW005.
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 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 1/31/2013 at 10:30 a.m., there was a non-patient RPT in room 2141 and 2155 all patient exam rooms.
2. On 1/31/2013 at 10:33 a.m., there were household use appliances in the staff break room.
3. On 1/31/2013 at 10:39 a.m., there was an RPT in the fish tank cabinet in the lobby.
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.

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 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 19.1.2.3, 19.1.1.4, 19.1.2.3). Findings include, but are not limited to:
1. On 1/30/2013 at 6:41 a.m., above door 3SDR6 there was exposed sheetrock tape, screws, gypsum wall board at the corner was not completed, and the right side was not taped above the door.
2. On 01/30/2013 at 6:52 a.m., there were exposed screws and sheetrock tape on elevator shaft at 3SDR5 next to staff elevator 3.
3. On 01/30/2013 at 7:48 a.m., there was sheetrock unfinished, not taped, five unsealed 2 inch penetrations, and one of the walls was not full height above the video camera at 2SDR6.
4. On 01/30/2013 at 7:53 a.m., there was only a single layer of sheetrock above 2SDR7.
5. On 01/30/2013 at 7:55 a.m., there were exposed screws, sheetrock tape, and unapproved patches on fire wall at 2SDR7.
6. On 01/30/2013 at 9:48 a.m., the fire wall was not completed at the room in the office of 4C20.
7. On 01/30/2013 at 9:59 a.m., the fire wall was not completed at the other side of corridor next to 4C20.
8. On 1/31/2013 at 8:11 a.m., there were two storage rooms near the ORs that were over 100 square feet and not separated from the suite by a 1 hour separation in room G121.
9. On 1/29/2013 at 2:00 p.m., the life safety drawings did not match actual buildings or as built construction documents.
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 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 01/29/2013 at 12:59 p.m., there were two unsealed 2 inch penetrations above door 4S16.
2. On 01/29/2013 at 3:10 p.m., five 1 inch unsealed penetrations were found at 3C18.
3. On 01/30/2013 at 7:17 a.m., there were exposed screws and the wall was not complete at 3W008.
4. On 1/29/2013 at 2:22 p.m., there were gaps around sprinkler heads in 3-S20 and 3-S15.
5. On 1/29/2013 at 2:30 p.m., there was a loose escutcheon ring and a gap around the sprinkler head in the restroom of room 3311.
6. On 1/29/2013 at 2:53 p.m., the escutcheon ring was missing in 3526.
7. On 1/29/2013 at 3:08 p.m., there was a loose escutcheon ring in the restroom of room 3201, 2305, conference room 1026 in Medical Education, in changing rooms 2, 3, and 4 for X-Ray 4/5.
8. On 1/30/2013 at 3:24 p.m., there was a missing escutcheon ring on sprinkler head in GH15.
9. On 1/31/2013 at 8:34 a.m., there was a dropped escutcheon ring in B081A, 2 dropped escutcheon rings in Room A of Sterile Processing, there were 2 escutcheon rings loose in Service Level Kitchen.
10. On 1/30/2013 8:20 a.m., there was a ¼ gap around sprinkler head in the restroom of room 2006 and the escutcheon plate was too small.
11. On 01/30/2013 at 7:48 a.m., there was a ½ inch unsealed penetration near 2SDR6.
12. On 01/30/2013 at 7:56 a.m., there were exposed screws and sheetrock tape above 2W001.14.
13. On 01/30/2013 at 8:05 a.m., there were ceiling penetrations and a ¼ inch space around conduit above 2W022.
14. On 01/30/2013 at 8:59 a.m., there were at least 5 penetrations in electrical room 2N8.
15. On 01/30/2013 at 9:34 a.m., there was an unoccupied room opening into the stairwell at 2SW4.
16. On 01/30/2013 at 2:07 p.m., there was a 3 inch hole in the ceiling tile near GW021.
17. On 01/30/2013 at 2:53 p.m., there were two 3 inch unsealed penetrations in G369A.
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 maintain exit corridor doors resist the passage of smoke into the means of egress in the event of a hostile fire event (LSC 19.2.3.5, Table 19.3.2.1, 19.3.6.3, Exception 2; A19.3.6.3.3). Findings include, but are not limited to:
1. On 1/29/13 at 1:19 p.m., there were roller latches on doors of linen closet 4S21.
2. On 1/31/2013 at 8:11 a.m., removed door for storage room G121 near ORs.
3. 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.
4. On 1/29/13 at 1:49 p.m., 1 ¼ inch undercut on the door to 4th floor 4103.
5. On 1/31/2013 at 8:09 a.m., door not latching adjacent to G105 and G102.
6. On 1/30/2013 at 9:12 a.m., roller latches on the doors for 2S21.
7. On 1/30/2013 at 9:25 a.m., roller latches on the doors for 2422.
8. On 1/30/2013 at 9:41 a.m., the door for 2444 does not latch.
9. On 1/30/2013 at 1:14 p.m., doors on ground level in 2 hour exit passage next to GSW01 do not latch.
10. On 1/30/2013 at 3:07 p.m., roller latches on the doors for G162.
11. On 1/30/2013 at 3:18 p.m., gap in top left corner of the door frame for G212.
12. On 1/31/2013 at 7:51 a.m., roller latches on door G264B in OR.
13. On 1/30/2013 at 7:20 a.m., drop prop being used at 3N002 a 90 minute fire door.
14.On 1/29/2013 at 1:11 pm, the corridor doors at elevator #4 4SDR2 were not closing.
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 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 1/29/2013 at 7:00 a.m., the emergency lights were plugged into wall in OR 1, OR 2.
2. On 1/29/2013 at 7:03 a.m., emergency light not hardwired and too low in OR 3, OR 4, & OR 6.
3. On 1/30/2013 at 3:00 p.m., there was no emergency light in Cath Lab 2.
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 maintain emergency preparedness plan current & readily available to all staff. 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 1/28/2013 during record review between 10:15 a.m. & 6:00 p.m., the Safety Officer had the only copy of the emergency preparedness manual and it lacked the following; no transportation agreement, the last annual review was 2005. There were flip charts of code responses at the maintenance shop and nurses stations that were outdated. There were two fires in 2012 and the facility did not notify the Office of State Fire Marshal, as required.
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 install fire alarm system in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 19.3.4, 9.6). Findings include, but are not limited to:
1. On 1/29/2013 at 12:56 p.m., there was a horn/strobe in stairwell 3 of the 4th floor, and 3rd floor, and 3SW2, 3N, 2SW2 of the 2nd floor, 2SWS of the 2nd floor, and throughout facility stairwells per Director of Facility Services.
2. On 1/29/2013 at 1:29 p.m., there were no chime strobes in 4th floor staff room 4C27, 4C28, 4C29, 4C23, 3312, 3314.
3. On 1/30/2013 at 6:48 a.m., there was no pull station at the 3rd floor west nurse station, no pull station at nurse station for ICU near room 2005, pull station obstructed at nurse station ICU North, blocked pull station at the nurse station 2SW, blocked pull station B128 by a chair, pull station blocked by printer and computer monitor in the Recovery room, pull station blocked by carts at nurse station short stay adjacent to G019, pull station blocked at nurse station across from G600B,
4. On 1/31/2013 at 7:50 a.m., there were strobes in patient restrooms G262, G245, G401G, & G403.
5. On 1/31/2013 at 9:53 a.m., there were no refrigerant leak detection alarms at the entrances for B043 chiller room.
6. On 1/29/2013 at 1:53 p.m., there was a battery powered smoke detector not wired into the fire alarm system in 4N15.
7. On 1/31/2013 at 8:08 a.m. there was no smoke detector within 5 feet of fire alarm panel in BW013.
8. On 1/29/2013 at 1:53 p.m., no chime/strobe in 4th floor staff room 4N15, 1N008, 1N003, 1N004, & 1N005.
9. On 1/30/2013 at 7:24 a.m. in room 310 across from elevator A, 3CL1 electrical panel breaker #12 there was no set screw.
10. On 1/30/2013 at 1:18 p.m., the pull station at ED entrance was blocked by wheelchairs.
11. 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.
12. On 1/30/2013 at 3:00 p.m., there was a notification device in Cath Lab 2 & 4, and a missing device in control room for Cath Lab 2 & 4.
13. On 1/30/2013 at 3:09 p.m., there was a strobe in patient area G158 & patient restrooms G150, G204, G151, GH18, & GH19.
14. On 1/31/2013 at 8:08 a.m. there was no smoke detector within 5 feet of fire alarm panel in BW013.
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 20.3.4, 9.6). Findings include, but are not limited to:
1. On 1/31/2013 at 10:43 a.m., there was no label on door to the fire alarm room or breaker.
2. On 1/31/2013 at 10:31 a.m., there was a strobe in the patient restroom 2204 and a strobe in X-ray room.
3. On 1/31/2013 at 10:40 a.m., there was no smoke detector within 5 feet of panel #20S1A-1, nor were the four batteries dated.
4. On 1/31/2013 at 10:40 a.m., in room 2133 there was a plastic dust cap on the smoke detector.
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 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 the facility record review between 10:15 a.m. & 6:00 p.m., there were no documentation of weekly, monthly, or quarterly testing, and the annual inspections conducted 9/22/11 and 11/20/12 were more than 12 months apart.
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 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 1/28/2013 at 11:00 a.m., there was an annual sprinkler report from Rainbow for December 2012, indicating that there was incomplete sprinkler coverage for the building and the facility had no documentation of making the corrections. The report noted the following: "a void in sprinkler coverage at the entrance to 115 A, a void in coverage at G530B and the hallway adjacent. Hallway signs affixed directly to ceiling on 1st floor blocking heads. The wash basin in the kitchen lacks one head."
2. On 1/29/2013 between 7:00 a.m. and 3:12 p.m., the following locations were found to be lacking proper sprinkler coverage or were deficiencies with the installation of the sprinkler system: there was missing or inadequate sprinkler coverage in OR 2, 3, 4, 6, 4S16, 4S24, 4C12, electrical room, near the entry door of 4H404, electrical room 3-S16, and in the showers of rooms 3207, 3208, 3209, 3206, 3202. There was an obstructed head in 3C21 first room and a missing sprinkler head in 3C21 second room. The standpipe on the roof was not labeled. The sprinkler riser gauge was not dated in the center penthouse. There were no caps on pipes in hose station cabinets near rooms 4307, 4101, & 3301.
3. On 1/30/2013 between 7:00 a.m. and 3:12 p.m., the following locations were found to be lacking proper sprinkler coverage or were deficiencies with the installation of the sprinkler system: room 2401, there was missing or inadequate sprinkler coverage in electrical room, 2205, 2204, 2C21, 2S16, far corner of 2414 and in the restroom of 2414, and in the showers of rooms 3117, 3111, 3110, 3108, 3101, 2010, 2207, 2206, 2202, 2203, 2310, 2414, 2412, 2406, 2402, and in rooms G1S69, 310 on the 3rd floor across from elevator A, back part of room G389, electrical rooms 210 and 211 across from elevator A, electrical room 1H114, there was no sprinkler coverage for the overhang covering combustibles such as wooden benches and trash cans at the main entrance 1st floor. There was one missing sprinkler head in x-ray 2. There was a permanent track blocking sprinkler head within 4 inches in room 2007. There was no cap on pipe in hose station cabinets near room 2522, near Chaplain Services office on 1st floor, next to elevator B 1st floor. room 2401 There was missing or inadequate sprinkler coverage in electrical room 2205, 2204, 2C21, 2S16, far corner of 2414 and in the restroom of 2414, and in the showers of rooms 3117, 3111, 3110, 3108, 3101, 2010, 2207, 2206, 2202, 2203, 2310, 2414, 2412, 2406, 2402, and in rooms G1S69, 310 on the 3rd floor across from elevator A, electrical rooms 210 and 211 across from elevator A, electrical room 1H114, there was no sprinkler coverage for the overhang covering combustibles such as wooden benches and trash cans at the main entrance 1st floor. There was one missing sprinkler head in x-ray 2. There was a permanent track blocking sprinkler head within 4 inches in room 2007. There was no cap on pipe in hose station cabinets near room 2522, near Chaplain Services office on 1st floor, next to elevator B 1st floor. There was no spare sidewall sprinkler heads in the sprinkler cabinet for the ED.
3. On 1/31/2013 between 7:00 a.m. and 10:00 a.m., the following locations were found to be lacking proper sprinkler coverage or were deficiencies with the installation of the sprinkler system: there was missing or inadequate sprinkler coverage in sterile processing office where a head was blocked with plastic, missing sprinkler coverage at wash area near dishwasher in kitchen on service level, B-072, at work fans in room B001, B102, alcove near stairs of SW5 service level, and under air handler exceeding 4' in SW5 on service level. There was no cap on pipe in hose station cabinets near room OR 6. The FDC at the loading dock was not marked with " FDC " signage in 6" letters red on white.
4. On 1/31/2013 at 8:54 a.m., the air compressor in the Epic training room BW023 has shut off switch installed, and the gauges were passed due for 5 year calibration or replacement.
5. On 1/31/2013 at 9:15 a.m., sprinkler protection for the chapel could not be verified.
6. On 1/31/2013 at 9:21 a.m., missing sprinkler head at B070.
7. On 1/31/2013 9:48 a.m., room off back of pharmacy was not fully sprinklered.
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 20.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. On 1/31/2013 at 10:30 a.m., there was a missing sprinkler head over the nurses station.
2. On 1/31/2013 at 10:55 a.m., there were combustibles stored under the non-sprinklered overhang in front of the ASC. Plants, trash cans, bicycles.
3. On 1/31/2013 at 10:55 a.m., there was no address on the FDC to identify which building it serviced and there was no FDC sign.
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. 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 1/31/2013 at 10:40 a.m., there were outdated gauges (2008) on the riser at the stairwell near 2133.
2. On 1/31/2013 at 10:40 a.m., there were no spare sidewall sprinkler heads at the riser near 2133.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.

Based on observations, record review 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. 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 01/28/2013 during record review between 10:15 a.m. & 6:00 p.m., there was no documentation for weekly or monthly testing of sprinklers. According to Director of Facility Services staff, they only do quarterly visual on sprinkler heads not monthly.
2. During the facility tour on 1/29/2013 between 7:00 a.m. & 5:30 p.m., the following deficiencies were noted with sprinkler heads: sprinkler heads had debris and were painted in OR 1; there was debris hanging from sprinkler head in OR 7; sprinkler head had sheetrock mud in C Section OR; sprinkler gauge in 4S17 4th floor soiled work room near elevator C dated 1974; obstructed sprinkler head in 4S15; painted sprinkler head in 4309; painted sprinkler head in restroom of 4309; painted sprinkler head 4S25 near Elevator #4 on the 4th floor; two painted sprinkler heads in 4S24; painted sprinkler head in restroom of room 4307; painted sprinkler head in restroom of room 4306; two painted sprinkler heads in room 4303; painted sprinkler head in room 4302; painted sprinkler head between door 4C35 and 4C34; painted sprinkler head 4C30; painted sprinkler heads throughout 4th floor center; painted sprinkler head 4C28; two painted sprinkler heads in room 4203; out dated sprinkler gauge in 4N10 Fire Sprinkler control valve; painted sprinkler head in alcove across 4N10; restroom of room 4105 missing escutcheon plates; painted sprinkler head in 4N15; painted sprinkler head in 4104; two painted sprinkler heads in 4103; painted sprinkler head in closet of 4102; sprinkler gauge in Fire Sprinkler Valve room 3-S18 is dated 1973; no cap on hose station cabinet near room 3301; & there was a dirty sprinkler head in 3208.
3. During the facility tour on 1/30/2013 between 3:00 a.m. & 4:30 p.m., the following deficiencies were noted with sprinkler heads: damaged sprinkler head in restroom of room 3016; damaged sprinkler head in 3004; painted sprinkler head 3117; corroded, painted, leaking sprinkler head in 3111; painted sprinkler head in room 3107; painted and dirt on the sprinkler head in MS2 next to elevator A on the 3rd floor; the gauge in sprinkler room 3N21 was dated 1973; red paint on sprinkler head in the 3N stairwell; painted sprinkler head at the SW1 door for stair 1 at the 2nd floor; sheetrock mud on sprinkler head in the restroom of room 2103; paint on sprinkler head in restroom of room 2102; damaged sprinkler head in restroom of 2007; paint and debris on sprinkler head in room 2207; sprinkler head in 2016 completely covered with paint and sheetrock mud; no escutcheon ring on sprinkler head in the staff lounge 2C11; painted sprinkler head in 2C21; painted sprinkler head in room 2312; dirty sprinkler head in room 2311; painted sprinkler head in restroom of room 2310; painted sprinkler head in room 2308; expired gauge in fire sprinkler room 2S18; damaged sprinkler head in the restroom of room 2302; painted sprinkler head in the restroom of room 2301; painted sprinkler head in the restroom of room 2406; dirty sprinkler head in the restroom of room 2402; corroded sprinkler head in the cashier office 181; painted sprinkler head in room 123; painted sprinkler head in soda closet of cafeteria kitchen 1st floor; gauge dated 1972 in fire sprinkler room 173; no spare sidewall sprinkler heads in the sprinkler cabinet for the ED; corroded sprinkler head G340A; dirty sprinkler heads in room G-355; 2 sprinkler gauges dated 1984 in G161; painted sprinkler head in G217B; corroded and wet sprinkler head outside of GH17; 2 corroded and wet sprinkler heads in GH17; 2 corroded and wet sprinkler heads in GH16; 2 corroded sprinkler heads in G14A; 2 corroded sprinkler heads next to GH12; & corroded sprinkler head next to GH09.
4. During the facility tour on 1/31/2013 between 6:30 a.m. & 12:30 p.m., the following deficiencies were noted with sprinkler heads: painted sprinkler head in G270A; damaged sprinkler head across from OR 3; corroded sprinkler head near dish washer in Service Level Kitchen; multiple corroded sprinkler heads in the Service Level Kitchen; sprinkler head by char broiler covered in grease in Service Level Kitchen; all sprinkler heads in Service Level Kitchen near hoods covered in grease; gauges dated 2006 in the Epic training room BW023; gauge on riser dated 1974 in storage room B074; gauge dated 1974 in B070; painted sprinkler head at electrical panel MCC-D1 in B010; painted sprinkler head north end of B010; painted sprinkler head in B091.
5. On 1/31/2013 at 7:30 a.m., the hydrant on the north side of the building near the loading dock was obstructed with vegetation and was not maintained 3' clear.
6. On 1/31/2013 at 7:40 a.m., annual fire pump test report on site was dated 8/3/2011.
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 fire extinguishers in accordance with adopted standards. 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 1/28/2013 at 2:00 p.m., the fire extinguisher WAR6 and AUM5 were listed as past due for 6 year hydrotest per the Valley report.
2. On 1/29/2013 during the facility tour between 7:00 a.m. & 5:30 p.m., the following fire extinguisher deficiencies were observed: the fire extinguisher was mounted too high in south penthouse on roof; fire extinguisher too high in 4S16; fire extinguisher too high 3-S16; & fire extinguisher obstructed near 3301.
3. On 1/30/2013 during the facility tour between 3:00 a.m. & 4:30 p.m., the following fire extinguisher deficiencies were observed: fire extinguisher too high adjacent to 2423; fire extinguisher obstructed in medical records room on the 1st floor; fire extinguisher obstructed in Lab; fire extinguisher obstructed across from G-355 in the lab; fire extinguisher obstructed in Pathology; fire extinguisher too high next to G351 in lab; & fire extinguisher too high next to G379.
4. On 1/31/2013 during the facility tour between 6:30 a.m. & 12:30 p.m., the following fire extinguisher deficiencies were observed: fire extinguisher too high in Sterile Processing room; fire extinguisher obstructed near the wash area in the Service Level Kitchen; fire extinguisher obstructed in Service Level Kitchen near the exit door; fire extinguisher obstructed by cart near the lockers in the Service Level Kitchen; 2 fire extinguishers were mounted too high in B010; no class A fire extinguisher in B105; & fire extinguisher in B-04S too high as well as too small.
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 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 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, and the hood filters and duct work were greasy on the day of the survey.
2. On 1/31/2013 at 8:40 a.m., suppression line under hood not secure and not aimed correctly above the stove in the Service Level Kitchen.
3. On 1/31/2013 at 8:40 a.m., there were 2 inch gaps in the hood filters above both of the cook tops in the Service Level Kitchen.

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 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 during the facility tour between 7:00 a.m. & 5:30 p.m., the following items were obstructing the corridor: a scale, supplies & soiled linen were stored in the corridor near 4312; charting stations near 4308 & 4310 did not automatically close; there was a vital sign cart charging in corridor near 4306; two portable charting carts charging in corridor near 4302 & one near 4105; three light fixtures extended into corridor 6.5 inches across from 4C1; two light fixtures extended into corridor 6.5 inches near room 4N110; chairs, tables, and plants in corridor outside 3308; wheelchairs in corridor near 3SW7.
2. On 1/29/2013 at 1:35 p.m., Maternity Care Coordinator office 4C20 open to corridor, missing door and partial wall only had a curtain.
3. On 1/29/2013 at 2:27 p.m., soiled linen in corridor near room 3302.
4. On 1/30/2013 during the facility tour between 3:00 a.m. & 4:30 p.m., the following items were obstructing the corridor: linen cart protruding 7 inches into the corridor across from room 3003; oxygen cylinders obstructing corridor across from nurse station in ICU near room 2007; chair at charting station reduced corridor to 7 feet across from room 2010, next to room 2202, next to room 2314, next to room 2302, next to room 2305 & next to room 2208;
5. On 1/30/2013 at 9:36 a.m., the charting station did not have an auto closure next to room 2406, and the charting station reduced corridor to less than 8 feet next to 2406.
6. On 1/30/2013 at 9:40 a.m., chairs at charting station reduced corridor to less than 8 feet near room 2401.
7. On 1/31/2013 at 8:15 a.m., storage space in Room H open to corridor across from wash sink and OR 8.
8. On 1/31/2013 at 9:12 a.m., chair at the top of the stairs for the 2 hour passageway SW8.
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 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 1/31/2013 at 10:30 a.m., there was a scale and soiled linen cart in the corridor near room 2145.
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 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 1/29/2013 at 12:57 p.m., there was a foam based plant in 4th floor lobby for elevator C.
2. On 1/29/2013 at 2:51 p.m., foam based plant near 3SW5.
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 provide safe storage for compressed gas in the oxygen storage room. This resulted in the potential for injury to staff and patients from a damaged compressed gas cylinder releasing unexpectedly. (LSC 18.3.2.4, 4.3.1.1.2). Findings include, but are not limited to:
1. On 1/30/2013 at 10:12 a.m., unsecured gas cylinders, only one chain in 2H213.
2. On 1/30/2013 at 11:15 a.m., 4 unsecured CO2 cylinders in the soda closet of the cafeteria.
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 systems 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 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 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 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 at 2:05 p.m., two power strips on the floor of 4H405, one hanging by the cord.
2. On 01/29/2013 at 2:06 p.m., non-patient power strip on the floor 4H413.
3. On 01/29/2013 at 2:06 p.m., power strip on the floor of 4H414.
4. On 01/29/2013 at 2:06 p.m., non-patient power strip on cart in 4H414.
5. On 01/29/2013 at 2:06 p.m., household coffee maker, microwave, and toaster in room 4H415.
6. On 01/29/2013 at 2:07 p.m. 4H415 had three power strips.
7. On 01/29/2013 at 2:07 p.m., non-patient power strip at printer across from 4H429.
8. On 01/29/2013 at 2:08 p.m., power strip on floor 4H429.
9. On 01/29/2013 at 2:09 p.m., extension cord and power strip on floor in board room 4H426.
10. On 01/29/2013 at 2:10 p.m., three power strips on the floor in Physical Therapy room 4H419.
11. On 01/29/2013 at 2:11 p.m., white extension cord plugged into power strip Physical Therapy room 4H420.
12. On 01/29/2013 at 2:11 p.m., two power strips on the floor in Physical Therapy room 4H420.
13. On 01/29/2013 at 2:11 p.m., two power strips on the floor in Physical Therapy room 4H421.
14. On 01/29/2013 at 2:12 p.m., power strip on floor at sink and at nurse station in the Physical Therapy room.
15. On 01/29/2013 at 2:35 p.m., two power strips on the floor of 3H300.
16. On 01/29/2013 at 2:37 p.m., power strip hanging by the cord in 3H302.
17. On 01/29/2013 at 2:37 p.m., power strip on the floor in 3H302.
18. On 01/29/2013 at 2:38 p.m., power strip on the floor at the nurse station across from 3H309.
19. On 01/29/2013 at 2:39 p.m. non-patient power strip in Exam 3H314.
20. On 01/29/2013 at 2:39 p.m., non-patient power strip on the floor of the nurse station near 3H315.
21. On 01/29/2013 at 2:40 p.m., power strip on the floor of 3H315 & 3H316.
22. On 01/29/2013 at 2:40 p.m., power strips daisy chained in 3H321.
23. On 01/29/2013 at 2:41 p.m., multiple power strips on the floor throughout the cardiovascular unit.
24. On 01/29/2013 at 2:41 p.m., household microwave, coffee maker, and toaster in 3H322.
25. On 01/29/2013 at 2:41 p.m., six to two plug adaptor in 3H322.
26. On 01/29/2013 at 2:43 p.m., multiple non-patient power strips throughout exam rooms in cardiovascular unit.
27. On 1/30/2013 at 10:15 a.m., household microwave and toaster in 2H204.
28. On 1/30/2013 at 10:23 a.m., non-patient power strip permanently attached in 2H225.
29. On 1/30/2013 at 10:24 a.m., non-patient power strip in 2H217.
30. On 1/30/2013 at 10:25 a.m., non-patient power strip in 2H215.
31. On 1/30/2013 at 1:18 p.m., non-listed space heather ED reception desk without three feet clearance.
32. On 1/30/2013 at 2:23 p.m., non-patient power strip at nurse station for ED.
33. On 1/30/2013 at 2:23 p.m., extension cord in GW009.
34. On 1/30/2013 at 2:24 p.m., household microwave, toaster, coffee pot in GW005.
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 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 1/31/2013 at 10:30 a.m., there was a non-patient RPT in room 2141 and 2155 all patient exam rooms.
2. On 1/31/2013 at 10:33 a.m., there were household use appliances in the staff break room.
3. On 1/31/2013 at 10:39 a.m., there was an RPT in the fish tank cabinet in the lobby.
Surveyor was accompanied by the Director of Facility Services who acknowledged the existence of these conditions.