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Based on review of facility documents, observation of the physical environment, and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not fulfilling all fire alarm system testing and maintenance requirements of NFPA 72 and NFPA 101.

The findings include:

1) During the survey at approximately 1000 hours on August 15, 2012 it was determined through review of the facility's documents and confirmed through interview with the Corporate Director/Safety Officer that all components of the fire alarm system are not documented as having been maintained as required by NFPA 72. The most recent Fire Alarm Inspection Reports from ARK Systems indicates that seven (7) Indicating Devices were tested throughout the entire facility. The testing documents should indicate a complete inventory of all Indicating Devices, as well as other components of the facility fire alarm system as required by NFPA 72.

2) Throughout the survey on August 15 and 16, 2012 it was determined through observation of the physical environment and confirmed through interview with the Corporate Director/Safety Officer that all components of the fire alarm system are not currently maintained as required by NFPA 72. Observation of the building fire alarm system annunciating panels revealed that the fire alarm system is experiencing an on-going "Trouble" condition. This is due to the malfunctioning, and subsequent removal of all initiating devices in the "MRI #2" room. The facility staff is working with the fire alarm vendor to remedy this situation, however, no solution has been developed as of this time. A required Fire Watch was originally in place for this area,. At this time all staff in the area have been made aware of the lack of initiating devices and are maintaining a heightened level of fire safety and awareness.

Failure to properly maintain all components of the building fire alarm system has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment, review of the facility's records, and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not having the building sprinkler and other fire suppression systems installed and maintained in accordance with NFPA 13, NFPA 14, and NFPA 25 to provide complete coverage for all portions of the building.

The findings include:

1) During the survey at approximately 1000 hours on August 16, 2012 it was observed and confirmed through interview with the Corporate Director/Safety Officer that the enclosed Exit Stairway from the first floor by Radiology leading up to the "EXIT" is not automatic sprinkler protected as required. This is a marked means of egress for the building. NFPA 13-8.15.3.2.

2) Throughout the survey n August 15 and 16, 2012 it was observed and confirmed through interview with the Corporate Director/Safety Officer that the building standpipe system testing is not documented as required. Test reports from FLSA indicate that only approximately eight (8) standpipe hose outlets are tested and serviced as required by NFPA 25. There are stairway and corridor standpipe hose outlets throughout the building in a much larger number than shown on the report(s).

3) During the survey at approximately 1130 hours on August 15, 2012 it was observed and confirmed through interview with the Corporate Director/Safety Officer that the automatic sprinkler heads in the storage rooms of the adjacent 6 th floor Shapiro Room and Palliative Care Office are missing escutcheons, have excessive gaps around them in the ceiling, and were observed to be covered with protective caps.

4) During the initial survey at approximately 1200 hours on August 15, 2012, it was observed and confirmed through interview with the Corporate Director/Safety Officer that the standpipe system vertical riser at the Roof Level of Stairway #9 lacks a pressure gauge as required by NFPA 14. All standpipe risers in the building shall be verified to be equipped with the required pressure gauges.

5) During the survey at approximately 1030 hours on August 16, 2012, it was observed and confirmed through interview with the Corporate Director/Safety Officer that the corridor standpipe 1.5" hose outlet on the Lower Level at Stairway #5 is missing the hand wheel required to open and close the outlet.

6) During the survey at approximately 1100 hours on August 16, 2012 it was observed and confirmed through interview with the Corporate Director/Safety Officer that the Fire Department Connection to the building sprinkler and standpipe system on the south side (McKenzie Street) of the building was obstructed from view by a large holly bush.

Failure to provide complete automatic sprinkler coverage to all parts of the building, and to properly maintain all components of the building fire suppression systems has the potential to promote harm to occupants of the facility in the event of a fire

Based on observation of the physical environment and interview with the facility staff it was determined that the facility staff failed to provide as safe an environment as possible by not having the kitchen hood ventilation and extinguishing system in compliance with NFPA 96 as required.

The findings include:

1). At approximately 1045 hours during the initial survey on August 16, 2012, it was determined through observation of the physical environment and confirmed through interview with the Corporate Director/Safety Officer that the (4 of 4) manual activation pull stations for the separate NFPA 96 required kitchen hood extinguishing systems are not labeled for the areas protected as required (NFPA 96-10.5.1).

The entire kitchen hood fire extinguishing system must comply with all aspects and requirements of NFPA 96.

Failure to insure that the kitchen hood extinguishing and ventilating system is in compliance with this Code has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based on observation of the physical environment and interviews with the facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not ensuring that the full width of the aisles and corridors serving as exit access are clear and are unobstructed as required.

The findings include:

1) During the initial survey on August 15, 2012 at approximately 1300 hours it was observed and confirmed through interview with that Corporate Director/Safety Officer that the Exit Corridor on the 5 th floor in the area of the PACU was obstructed to less than the required full clear width. The full width of the corridor (8') was obstructed and reduced (to 5') due to the storage of eight (8) hospital beds in this area The beds were in the corridor longer than permitted to be considered "temporary" or "in use".

The reduced width of the corridors has the potential to promote harm to occupants of the facility in the event of an emergency.

Based on observation of the physical environment and interview with the facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining medical gas storage in accordance with NFPA 99.

The findings include:

1). During the initial survey on August 15, 2012 at approximately 1345 hours it was observed and confirmed through interview with the Corporate Director/Safety Officer that the Respiratory Therapy storage room on the 3rd floor near the ICU is lacking signs indicating oxidizing medical gases are stored within. There were observed to be approximately nine (9) nitric oxide cylinders and one (1) "E" size oxygen cylinders in racks in this room. This room must meet all NFPA requirements for oxidizing gas storage based on the total potential cubic feet of gas to be stored within.

The failure to equip medical gas storage rooms with the required identifying signs, and to abide by all NFPA requirements for medical gas storage has the potential to promote harm to occupants of the building in the event of a fire in this area.

Based on review of facility documents, observation of the physical environment, and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not fulfilling all fire alarm system testing and maintenance requirements of NFPA 72 and NFPA 101.

The findings include:

1) During the survey at approximately 1000 hours on August 15, 2012 it was determined through review of the facility's documents and confirmed through interview with the Corporate Director/Safety Officer that all components of the fire alarm system are not documented as having been maintained as required by NFPA 72. The most recent Fire Alarm Inspection Reports from ARK Systems indicates that seven (7) Indicating Devices were tested throughout the entire facility. The testing documents should indicate a complete inventory of all Indicating Devices, as well as other components of the facility fire alarm system as required by NFPA 72.

2) Throughout the survey on August 15 and 16, 2012 it was determined through observation of the physical environment and confirmed through interview with the Corporate Director/Safety Officer that all components of the fire alarm system are not currently maintained as required by NFPA 72. Observation of the building fire alarm system annunciating panels revealed that the fire alarm system is experiencing an on-going "Trouble" condition. This is due to the malfunctioning, and subsequent removal of all initiating devices in the "MRI #2" room. The facility staff is working with the fire alarm vendor to remedy this situation, however, no solution has been developed as of this time. A required Fire Watch was originally in place for this area,. At this time all staff in the area have been made aware of the lack of initiating devices and are maintaining a heightened level of fire safety and awareness.

Failure to properly maintain all components of the building fire alarm system has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment, review of the facility's records, and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not having the building sprinkler and other fire suppression systems installed and maintained in accordance with NFPA 13, NFPA 14, and NFPA 25 to provide complete coverage for all portions of the building.

The findings include:

1) During the survey at approximately 1000 hours on August 16, 2012 it was observed and confirmed through interview with the Corporate Director/Safety Officer that the enclosed Exit Stairway from the first floor by Radiology leading up to the "EXIT" is not automatic sprinkler protected as required. This is a marked means of egress for the building. NFPA 13-8.15.3.2.

2) Throughout the survey n August 15 and 16, 2012 it was observed and confirmed through interview with the Corporate Director/Safety Officer that the building standpipe system testing is not documented as required. Test reports from FLSA indicate that only approximately eight (8) standpipe hose outlets are tested and serviced as required by NFPA 25. There are stairway and corridor standpipe hose outlets throughout the building in a much larger number than shown on the report(s).

3) During the survey at approximately 1130 hours on August 15, 2012 it was observed and confirmed through interview with the Corporate Director/Safety Officer that the automatic sprinkler heads in the storage rooms of the adjacent 6 th floor Shapiro Room and Palliative Care Office are missing escutcheons, have excessive gaps around them in the ceiling, and were observed to be covered with protective caps.

4) During the initial survey at approximately 1200 hours on August 15, 2012, it was observed and confirmed through interview with the Corporate Director/Safety Officer that the standpipe system vertical riser at the Roof Level of Stairway #9 lacks a pressure gauge as required by NFPA 14. All standpipe risers in the building shall be verified to be equipped with the required pressure gauges.

5) During the survey at approximately 1030 hours on August 16, 2012, it was observed and confirmed through interview with the Corporate Director/Safety Officer that the corridor standpipe 1.5" hose outlet on the Lower Level at Stairway #5 is missing the hand wheel required to open and close the outlet.

6) During the survey at approximately 1100 hours on August 16, 2012 it was observed and confirmed through interview with the Corporate Director/Safety Officer that the Fire Department Connection to the building sprinkler and standpipe system on the south side (McKenzie Street) of the building was obstructed from view by a large holly bush.

Failure to provide complete automatic sprinkler coverage to all parts of the building, and to properly maintain all components of the building fire suppression systems has the potential to promote harm to occupants of the facility in the event of a fire

Based on observation of the physical environment and interview with the facility staff it was determined that the facility staff failed to provide as safe an environment as possible by not having the kitchen hood ventilation and extinguishing system in compliance with NFPA 96 as required.

The findings include:

1). At approximately 1045 hours during the initial survey on August 16, 2012, it was determined through observation of the physical environment and confirmed through interview with the Corporate Director/Safety Officer that the (4 of 4) manual activation pull stations for the separate NFPA 96 required kitchen hood extinguishing systems are not labeled for the areas protected as required (NFPA 96-10.5.1).

The entire kitchen hood fire extinguishing system must comply with all aspects and requirements of NFPA 96.

Failure to insure that the kitchen hood extinguishing and ventilating system is in compliance with this Code has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based on observation of the physical environment and interviews with the facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not ensuring that the full width of the aisles and corridors serving as exit access are clear and are unobstructed as required.

The findings include:

1) During the initial survey on August 15, 2012 at approximately 1300 hours it was observed and confirmed through interview with that Corporate Director/Safety Officer that the Exit Corridor on the 5 th floor in the area of the PACU was obstructed to less than the required full clear width. The full width of the corridor (8') was obstructed and reduced (to 5') due to the storage of eight (8) hospital beds in this area The beds were in the corridor longer than permitted to be considered "temporary" or "in use".

The reduced width of the corridors has the potential to promote harm to occupants of the facility in the event of an emergency.

Based on observation of the physical environment and interview with the facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining medical gas storage in accordance with NFPA 99.

The findings include:

1). During the initial survey on August 15, 2012 at approximately 1345 hours it was observed and confirmed through interview with the Corporate Director/Safety Officer that the Respiratory Therapy storage room on the 3rd floor near the ICU is lacking signs indicating oxidizing medical gases are stored within. There were observed to be approximately nine (9) nitric oxide cylinders and one (1) "E" size oxygen cylinders in racks in this room. This room must meet all NFPA requirements for oxidizing gas storage based on the total potential cubic feet of gas to be stored within.

The failure to equip medical gas storage rooms with the required identifying signs, and to abide by all NFPA requirements for medical gas storage has the potential to promote harm to occupants of the building in the event of a fire in this area.