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Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator and that the facility failed to maintain the integrity of smoke separations for the building.
This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5).
Findings include, but are not limited to:
1. On 5/6/2015, at 9:08 a.m., there was fire protective material missing from the structural steel within Penthouse "B" in the northeast corner behind ASU6.
2. On 5/7/2015, at 10:15 a.m., there was an unsealed wall penetration that measured approximately 1/2" within the 1-hour separation wall adjacent to B122 door within the basement of the facility.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to maintain the integrity of smoke separations for hazardous rooms.
This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5).
Findings include, but are not limited to:
1. On 5/6/2015, at 9:42 a.m., there were multiple unsealed wall penetrations above the separation doors at both ends of the western elevated Pedestrian Walk-Way.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator 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 5/7/2015, at 8:14 a.m., there was a gap at the top of the cross-corridor doors (3008) that measured approximately 1/2" or greater.
2. On 5/7/2015, at 8:56 a.m., there was a door to a janitorial closet (2102) that was not latching closed completely.
3. On 5/7/2015, at 9:45 a.m., the cross-corridor doors (B009) within the basement were not closing and latching completely, locking mechanism appears to be not functioning or sticking.
4. On 5/7/2015, at 9:48 a.m., the 90-minute smoke doors outside the surgery waiting room were not closing or latching closed completely.
5. On 5/7/2015, at 10:17 a.m., there was a door (B119) within the 1-hour separation wall within the basement that was held open with a unapproved hold open device and was also blocked by a service cart not allowing the door to close completely.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Staff 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 for the building (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 5/5/2015, at 2:50 p.m., Patient Rm. 121 corridor door would not close or latch properly.
2. On 5/5/2015, at 2:56 p.m., Patient Rm. 128 corridor door had an approximate gap of 1/2" or greater at the top of the door.
3. On 5/5/2015, at 3:08 p.m., the Environmental Services Storage Rm. near the sleep lab would not latch or close properly. Upon inspection by the surveyor, there had been material placed into the latching mechanism to prevent the door from closing and latching properly.
4. On 5/5/2015, at 3:15 p.m., the fire doors adjacent to the Oxygen Storage room failed to close properly.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to maintain approved smoke barrier doors of the building.
This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 19.2.3.5, (Table 18.3.2.1), 19.3.6.3, 4.6.12.1).
Findings include, but are not limited to:
1. On 5/6/2015, at 10:15 a.m., there was a smoke gasket missing or had become attached from the top of the doorway to ITF Room 6409.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Staff that the facility failed to provide a one hour separation between hazardous areas and the corridor for the building.
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, 8.4).
Findings include, but are not limited to:
1. On 5/5/2015, at 2:19 p.m., the former film storage room was being utilized for storage of combustible materials and was not separated properly as a hazardous room.
2. On 5/5/2015, at 2:28 p.m., the doors leading from the Lobby into the Laboratory would not latch or close properly when placed on the door coordinator.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator 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 19.2.8).
Findings include, but are not limited to:
1. On 5/5/2015, during record review between 8:00 a.m. and 5:00 p.m., there was no documentation showing the required monthly 30 second test or annual 90 minute test on emergency lights within the facility.
2. On 5/6/2015, at 8:42 a.m., there was an emergency battery powered egress light within the Verizon Equipment Room that failed to work when the test button was depressed.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to maintain emergency preparedness plan current & readily available to all staff, affecting the entire building.
This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1).
Findings include, but are not limited to:
1. On 5/5/2015, during record review between 9:00 a.m. and 5:00 p.m., the disaster plan provided by the facility to the surveyor did not have a facility map showing the physical locations of utility shutoffs (electric, gas, water, etc.) in the event the utilities needed to be shut down during/after an emergency event.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to provide fire drills for all staff affecting the entire building.
This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents 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 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., facility documentation presented to the surveyor showed that fire drills for day shift in 2014 and 2015 were not being staggered throughout the entire shift. Fire drills were conducted between 8:56 a.m. to 9:29 a.m.
2. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., facility documentation presented to the surveyor showed that fire drills for swing shift in 2014 and 2015 were not being staggered throughout the entire shift. Fire drills were conducted between 8:00 p.m. to 8:25 p.m.
3. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., facility documentation presented to the surveyor showed that fire drills for night shift in 2014 and 2015 were not being staggered throughout the entire shift. Fire drills were conducted between 12:30 a.m. and 1:58 a.m.
4. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such but not limited to number of simulated evacuated patients, specific location of simulated fire, specific type of fire simulated, staff performance and time to completed simulated evacuation of occupants within the affected smoke compartment to an unaffected smoke compartment.
Operating Engineer stated that staff do not simulate the evacuation of patients and staff were silencing fire alarm to reduce the impact to patients and not letting the fire alarm sound during the entire fire drill. Fire drill that was conducted on 12/3/2014 on the 4th floor noted that Nuclear Medicine Staff refused to participate in the drill. All staff must participate in all Fire Drills within the facility.
Fire drill form dated 2/26/2014 noted that Clinical Nurse Manager did not have access to two Physician Sleep Rooms on Floor 3 and was unable to check rooms for occupancy. Fire drill documentation also states that 50% of drills shall be unannounced when all drills shall be unannounced.
5. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., Code Red-Fire Policy instructs the placement of towels or pillows at the foot of the Patient Rm. doors after Patient Rm's. have been evacuated. The placement of pillow or towels at the base of doors within the corridors create an obstruction during relocation of other patients on the floor and would provide combustible materials within the corridor.
Policy also states the it was up to the desecration of the Charge Nurse on removing patients from the affected smoke compartment to an unaffected smoke compartment.
6. On 5/7/2015, at 1:51 p.m., a fire drill was conducted by the surveyors and the following observations were noted: Staff did not clear the corridors in the affected smoke compartment or adjoining unaffected smoke compartments, no simulated evacuation of patients from the affected smoke compartment to the unaffected smoke compartment, no staff communication or leadership, fire alarm pull station was not activated, fire alarm system did not function (not initiated by staff), staff were complacent and some staff continued to work at their computers.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Engineering Staff that the facility failed to provide fire drills for all staff affecting the entire building.
This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents 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 5/5/2015, during record review between 6:30 a.m. and 8:30 a.m., fire drill documentation presented to the surveyor showed that fire drills for day, swing and night shifts were not being staggered.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Staff that the facility failed to install fire alarm system in accordance with NFPA 72 "private mode" systems.
This resulted in the potential for delay and panic during fire emergencies (LSC 19.3.4, 9.6).
Findings include, but are not limited to:
1. On 5/5/2015, at 1:58 p.m., the breakers for the Fire Alarm Control Panel were not labeled with a red "FACP" label.
2. On 5/5/2015, at 1:58 p.m., the breakers for the Fire Alarm Control Panel did not have mechanical set screw locks installed on the breakers.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to test and maintain fire alarm in accordance with NFPA 72 for the entire building.
This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72).
Findings include, but are not limited to:
1. On 5/5/2015, during record review between 8:00 a.m. and 5:00 p.m., monthly and quarterly testing and maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the fire alarm system to the adopted 1999 edition of NFPA 72 standards.
2. On 5/7/2015, at 8:14 a.m., there was a smoke detector within Patient Rm. 302 that had come loose from the ceiling.
3. On 5/7/2015, at 9:15 a.m., there was a missing red "FACP" label next to the breaker controlling the buildings fire alarm control panel.
4. On 5/7/2015, at 9:15 a.m., there was a missing mechanical set screw lock on the electrical breaker controlling the main Fire Alarm Control Panel.
5. On 5/7/2015, at 9:15 a.m., there was missing signage on the main Fire Alarm Control Panel identifying the location and breaker number of the Fire Alarm Control Panel.
6. On 5/7/2015, at 9:17 a.m., there were missing door signage (FACP or Fire Alarm Control Panel) for door B808 and B005 to help responding personnel in locating the fire alarm control panel.
7. On 5/7/2015, at 11:08 a.m., there was a fire alarm pull station that was blocked or obstructed by a cabinet within the Laboratory adjacent to door 1516.
8. On 5/8/2015, at 10:46 a.m., the notification devices for the fire alarm system within the building were observed not be synchronized for floor 4 and 5. This condition was observed during a fire drill by the surveyors as they stood near a main bank of elevators for the facility.
9. On 5/8/2015, at 1:00 p.m., there was a fire alarm pull station that was installed more then 60" from the finish floor to the operating handle within Foyer 2012A adjacent to door S-203.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator 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 5/6/2015, at 5:34 a.m., there was missing automatic sprinkler protection within OR #1, OR #2, OR #3, OR #4, OR #5, OR #6 and OBOR Delivery Rm. #2.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Staff that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition for the 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 5/5/2015, at 3:02 p.m., the automatic sprinkler head had dropped from the ceiling creating a hole into the attic space within the Storage Supply Room adjacent to Occupational Therapy.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to ensure the sprinkler system was 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 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., weekly, monthly, and quarterly testing and maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the sprinklers to the adopted 1998 edition of NFPA 25 standards.
2. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., monthly testing and maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the facilities fire pump to the adopted 1998 edition of NFPA 25 standards.
3. On 5/6/2015, during record review between 8:00 a.m. and 5:00 p.m., there was no integrity testing information for the fixed fire protection system that was located within the Verizon Equipment Room. The "silence" button for this system was not functioning when tested.
4. On 5/6/2015, during the facility tour between 5:30 a.m. and 11:00 a.m., there were missing escutcheon plates on automatic sprinkler heads within the Central Processing Decontamination area and Rm. 2818 in the 7th Avenue Bldg.
5. On 5/6/2015, during the facility tour between 5:30 a.m. and 11:00 a.m., there were damaged automatic sprinkler heads that need to be replaced within the Sterile Processing Clean Side area above the first pass through window and Soiled Utility (Rm 2401) in the 7th Avenue Bldg.
6. On 5/6/2015, at 8:44 a.m., the packing nut on the Standpipe valve located on the roof of the the East Center was loose.
7. On 5/7/2015, during the facility tour between 8:30 a.m. and 12:00 p.m., there were painted automatic sprinkler heads, that need to be replaced, within the Riser Room on the 2nd floor adjacent to Rm. 2104, Rm. B507 and Restroom of the Physician Lounge on Floor 1.
8. On 5/7/2014, during the facility tour between 8:30 a.m. and 12:00 p.m., there were damaged automatic sprinkler heads, that need to be replaced, within the corridor adjacent to Rm. 2228 and Restroom 1188.
9. On 5/7/2015, during the facility tour between 8:30 a.m. and 12:00 p.m., there were missing escutcheon plates on automatic sprinkler heads within the ICU Physical Documentation room, Dish Rm. (near south wall) and Rm. 2352.
10. On 5/7/2015, at 9:53 a.m., the Anti-Freeze Sprinkler Loop for the East Carport shows signs of leaking and corrosion on the control valve. System was located in Rm. 2357.
11. On 5/7/2015, at 10:50 a.m., there was a corroded automatic sprinkler head, that needs to be replaced, within the Walk-In Refrigerator within the Main Kitchen.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to maintain fire extinguishers in accordance with adopted standards for the facility.
This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10).
Findings include, but are not limited to:
1. On 5/6/2015, at 11:30 a.m., there was a missing minimum 10A 120B rated fire extinguisher (Aircraft measured between 50' - 80') for the facilities rooftop Helistop. Fire extinguisher present at the rooftop was only a 4A 60B:C sized extinguisher.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Staff that the facility failed to maintain fire extinguishers in accordance with adopted standards for the facility.
This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10).
Findings include, but are not limited to:
1. On 5/5/2015, at 1:55 p.m., there was a fire extinguisher within the boiler room that was not properly mounted as evidence of the extinguisher sitting on the floor.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to install/maintain an approved ventilation hood and duct system.
This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 4.6.12.1, 9.2.3, 19/18.3.2.6, NFPA 96 A.1.1.4, UL300).
Findings include, but are not limited to:
1. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., Simplex Grinnell (3rd party vendor) noted on their annual inspection report that the Cafe Hood was only 15" from the cooking surface and not the required 18" from the cooking surface and the hood was not a UL300 listed hood.
2. On 5/7/2015, at 10:56 a.m., the cooking surface and fryer within the cafe did not have adequate separation or an adequate baffle plate between the two cooking devices.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator 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 of the building.
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 5/6/2015, at 10:51 a.m., there were wall mounted computer terminals/charting stations that would not close and retract fully to a closed position when opened and released. Terminals and stations were adjacent to Pt. Rm. 5523 and Pt. Rm. 5537.
2. On 5/7/2015, at 10:00 a.m., there were shielding devices for the Nuclear Medicine area that were stored within the egress corridor outside door B417 which created a corridor obstruction within the constructed clear width.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Staff that the facility failed to ensure that no curtains of highly flammable character were used in the building.
This resulted in the potential for excessive fire spread (LSC 19.7.5.1).
Findings include, but are not limited to:
1. On 5/5/2015, during the facility tour between 8:30 a.m. and 3:30 p.m., there were non -fire treated quilts hanging on the walls within the corridors and conference rooms throughout the facility including but not limited to: Social Work Conference Room, Conference Rm. 1 & 3 and corridor outside of Conference Rm's.

Based on observations and interviews it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to provide safe storage for compressed gas.
This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks. (LSC 19.3.2.4, NFPA 99 4.3.1.1.2).
Findings include, but are not limited to:
1. On 5/7/2015, at 9:40 a.m., there were compressed gas cylinders being stored within Rm. B707 (Respiratory Therapy Storage) that had electrical switches and outlets within 60" of the finish floor.
2. On 5/7/2015, at 10:58 a.m., there were compressed gas cylinders that were not properly secured by evidence of the cylinders of a single chain near the top of the cylinders that would allow the bottoms of the cylinders to kick out and strike other cylinders or walls within the exterior LOX storage area during a seismic event.
3. On 5/7/2015, at 10:58 a.m., there were 5-compressed gas cylinders that were not properly secured by evidence of the cylinders standing in a free non-restrained fashion that would allow the cylinders to fall and strike other cylinders or walls within the exterior LOX storage area during a seismic event.

Based on record review and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator 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 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., documentation provided to the surveyor showed that outlets, shutoff valves, flexible connectors, automatic pressure switches and master signal panels were being inspected and maintained by staff and staff did not have technician competence in maintaining the piped medical gas system for the facility.

Based on record review and interviews during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1.
This resulted in the potential for injury to patients during medical procedures.
Findings include, but are not limited to:
1. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., the humidity policy provided by staff only provided guidelines on what to do in the event that the humidity was greater then 70%.
Policy states that humidity shall be maintained between 20% and 70% and Humidity logs show the humidity range to be between 30% and 70%. Humidity logs provided to the surveyor showed humidity levels less than 30% on the following days: OR #1 on 2/5-7/2014, 2/10/2014, 11/11-12/2014, 11/17/2014, 12/30-31/2014, 2/17/2015 and 2/23/2015; OR #2 on 2/4-7/2014, 2/10/2014, 11/11-13/2014, 11/17-18/2014, 12/1/2014, 12/30-31/2014, 1/2/2015, 2/23-24/2015 and 3/4/2015; OR #3 on 1/6/2014, 1/24/2014, 2/4-7/2014, 2/10/2014, 2/26/2014, 11/11-13/2014, 11/17-19/2014, 12/1/2014, 12/3/2014, 12/30-31/2014, 1/2/2015, 2/23-24/2015 and 3/4/2015; OR #4 on 2/4-7/2014, 2/10/2014, 11/11-13/2014, 11/17-18/2014, 12/1/2014, 12/30-31/2014 and 2/23/2015; OR #6 on 2/5-7/2014, 2/10/2014, 11/11-13/2014, 11/17-18/2014, 12/30-31/2014 and 2/23/2015; OR #7 on 1/6/2014, 2/6-7/2014, 2/10/2014, 11/11-13/2014, 11/17-19/2014, 12/1-3/2014, 12/30-31/2014, 1/2/2015 and 2/21/2015.
2. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., there were no humidity logs being kept for the TOPS OR's within the 7th Street Building and the "Humidity Watch Policy" only addressed what to do or who to contact in the event that the humidity was greater than 70%.

Based on observations and interviews it was determined, through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to properly store building service equipment for the building.
This resulted in the potential for unexpected fire (LSC 19.5.2.1, 19.5.2.2, 9.2, NFPA 90A).
Findings include, but are not limited to:
1. On 5/7/2015, at 10:55 a.m., there was a propane barbeque grill with a propane tank connected to the barbeque stored within the kitchen of the facility under a Type II Hood system.

Based on observations, record review and interviews it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to properly maintain the generator affecting the entire facility.
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 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., documentation provided by the facility showed only 2-hr. load bank tests (3/2013 and 4/2013) for both generators and not the required 3-year, 4-hour, minimum 80% nameplate load bank test.
2. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., documentation provided by the facility showed that weekly Electrolyte and monthly Specific Gravity test were not being completed because the generators were equipped with maintenance free batteries.
3. On 5/5/2015, at 11:23 a.m., there was no emergency stop button installed outside the generator enclosure for both generators.

Based on observations, record review and interviews it was determined through on-going dialog with the Engineering Staff that the facility failed to properly maintain the generator affecting the entire facility.
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 5/5/2015, at 1:57 p.m., batteries for the generator were observed to be maintenance free batteries. Facility staff cannot conduct required weekly and monthly maintenance and testing on the generator batteries.
2. On 5/5/15, during record review between 6:30 a.m. and 8:30 a.m., documentation provided to the surveyor showing the required 3-year, 4-hour load bank test was not completed correctly according to NFPA 110 standards as it was conducted at a percentage of the nameplate lower then what was required.

Based on record review and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to provide an alternate source of power in accordance with NFPA 99 3.6, which would provide a minimum of 90 minutes of power in an outage.
This resulted in the potential for panic and confusion for staff and residents in a power outage.
Findings include, but are not limited to:
1. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., there was no documentation provided showing the required monthly or quarterly maintenance and inspection on the Stored Electrical Emergency Power System and staff did not have technician competence in maintaining the system to the adopted 1996 edition of NFPA 111 standards.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for the building.
This resulted in the potential for injury to residents & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 5/6/2015, at 5:44 a.m., there was a broken electrical outlet within OR #5.
2. On 5/6/2015, at 8:52 a.m., there was an open electrical junction box within Penthouse "C" above switch EF-1A.
3. On 5/6/2015, at 10:09 a.m., there was an electrical cord to a black light that was attached to the wall and routed around a ceiling tile within Tuality Health Alliance Office, 6th floor.
4. On 5/7/2015, during the facility tour between 9:00 a.m. and 1:00 p.m., there were missing electrical outlet covers on outlets within Rm. 2101, Rm. 2209 and Rm. 2210.
5. On 5/7/2015, at 9:08 a.m., there was a electrical transformer that showed signs of overheating by discoloration within the Phone Rm. (Door B808) adjacent to the main Fire Alarm Control Panel.
6. On 5/7/2015, at 9:17 a.m., there were exposed non-energized electrical wires from an old clock wall mount within Rm. 2117.
7. On 5/7/2015, at 9:58 a.m., there was a broken GFI electrical outlet within the Soiled Utility Room of Day Surgery.
8. On 5/7/2015, during the facility tour between 9:00 a.m. and 1:00 p.m., there were relocatable power taps (RPT's) on the floor within the following locations but not limited to: RT Office/Charting Area, B113, B420, B104, B209, B305 Pharmacy, B404 Purchasing, Laboratory and B609.
9. On 5/7/2015, during the facility tour between 9:00 a.m. and 1:00 p.m., there were relocatable power taps (RPT's) within patient treatment/care areas that were not UL60601-1 listed. RPT's observed in the following areas but not limited to: B420, B413, Injection Area, Rapid Care Unit Rm. #4 and Nuclear Medicine.
10. On 5/7/2015, during the facility tour between 9:00 a.m. and 1:00 p.m., there were relocatable power taps that were "daisy chained" together within room B113 and Library Manager's Office.
11. On 5/7/2015, at 10:25 a.m., there was a household grade microwave within the Housekeeping Breakroom (B120).

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for the building.
This resulted in the potential for injury to residents & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 5/5/2015, at 2:02 p.m., there was a broken electrical outlet cover adjacent to the headboard of Bed #2 within the Emergency Department.
2. On 5/5/2015, at 2:02 p.m., there was a missing electrical outlet cover and a half cover installed on a 4x4 junction box within the ITF Room.
3. On 5/5/2015, at 2:14 p.m., there was a power supply for the monitor located within the corridor of the Negative Pressure Room that was routed through the corridor wall from an electrical outlet inside the room.
4. On 5/5/2015, at 3:24 p.m., there was an open electrical junction box on the facility side of the 2-hour separation with the attached Dialysis Center.

Based on the observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to install alcohol based hand rub (ABHR) dispensers away from sources of ignition for the building.
This resulted in the potential for injury to residents and staff (LSC 19.3.2.6, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623).
Findings include, but are not limited to:
1. On 5/6/2015, during the facility tour between 9:00 a.m. and 1:00 p.m., there were Alcohol Based Hand Rub dispensers that were installed above electrical outlets or switches in the following locations but not limited to: Operating Rm. #2, Break Room on the 5th Floor, Rm. 4410, outside the Clean Core Rm. 2208 in the 7th Avenue Bldg., and Post Op Rm. 2113 in the 7th Avenue Bldg.
2. On 5/7/2015, during the facility tour between 9:00 a.m. and 1:00 p.m., there were Alcohol Based Hand Rub dispensers that were installed above electrical outlets or switches in the following locations but not limited to: B702, B706, adjacent to door 1532, Rm. 3327, Rm. 2224, and the Employee Health Office.

Based on the observations and interview during the survey, it was determined through on-going dialog with the Engineering Staff that the facility failed to install alcohol based hand rub (ABHR) dispensers away from sources of ignition for the building.
This resulted in the potential for injury to residents and staff (LSC 19.3.2.6, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623).
Findings include, but are not limited to:
1. On 5/5/2012, at 2:52 p.m., there were alcohol based hand rub dispensers installed above electrical switches and outlets within the following locations but not limited to: Equipment Storeroom and Geriatric Psychiatric area.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator and that the facility failed to maintain the integrity of smoke separations for the building.
This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5).
Findings include, but are not limited to:
1. On 5/6/2015, at 9:08 a.m., there was fire protective material missing from the structural steel within Penthouse "B" in the northeast corner behind ASU6.
2. On 5/7/2015, at 10:15 a.m., there was an unsealed wall penetration that measured approximately 1/2" within the 1-hour separation wall adjacent to B122 door within the basement of the facility.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to maintain the integrity of smoke separations for hazardous rooms.
This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5).
Findings include, but are not limited to:
1. On 5/6/2015, at 9:42 a.m., there were multiple unsealed wall penetrations above the separation doors at both ends of the western elevated Pedestrian Walk-Way.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator 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 5/7/2015, at 8:14 a.m., there was a gap at the top of the cross-corridor doors (3008) that measured approximately 1/2" or greater.
2. On 5/7/2015, at 8:56 a.m., there was a door to a janitorial closet (2102) that was not latching closed completely.
3. On 5/7/2015, at 9:45 a.m., the cross-corridor doors (B009) within the basement were not closing and latching completely, locking mechanism appears to be not functioning or sticking.
4. On 5/7/2015, at 9:48 a.m., the 90-minute smoke doors outside the surgery waiting room were not closing or latching closed completely.
5. On 5/7/2015, at 10:17 a.m., there was a door (B119) within the 1-hour separation wall within the basement that was held open with a unapproved hold open device and was also blocked by a service cart not allowing the door to close completely.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Staff 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 for the building (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 5/5/2015, at 2:50 p.m., Patient Rm. 121 corridor door would not close or latch properly.
2. On 5/5/2015, at 2:56 p.m., Patient Rm. 128 corridor door had an approximate gap of 1/2" or greater at the top of the door.
3. On 5/5/2015, at 3:08 p.m., the Environmental Services Storage Rm. near the sleep lab would not latch or close properly. Upon inspection by the surveyor, there had been material placed into the latching mechanism to prevent the door from closing and latching properly.
4. On 5/5/2015, at 3:15 p.m., the fire doors adjacent to the Oxygen Storage room failed to close properly.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to maintain approved smoke barrier doors of the building.
This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 19.2.3.5, (Table 18.3.2.1), 19.3.6.3, 4.6.12.1).
Findings include, but are not limited to:
1. On 5/6/2015, at 10:15 a.m., there was a smoke gasket missing or had become attached from the top of the doorway to ITF Room 6409.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Staff that the facility failed to provide a one hour separation between hazardous areas and the corridor for the building.
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, 8.4).
Findings include, but are not limited to:
1. On 5/5/2015, at 2:19 p.m., the former film storage room was being utilized for storage of combustible materials and was not separated properly as a hazardous room.
2. On 5/5/2015, at 2:28 p.m., the doors leading from the Lobby into the Laboratory would not latch or close properly when placed on the door coordinator.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator 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 19.2.8).
Findings include, but are not limited to:
1. On 5/5/2015, during record review between 8:00 a.m. and 5:00 p.m., there was no documentation showing the required monthly 30 second test or annual 90 minute test on emergency lights within the facility.
2. On 5/6/2015, at 8:42 a.m., there was an emergency battery powered egress light within the Verizon Equipment Room that failed to work when the test button was depressed.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to maintain emergency preparedness plan current & readily available to all staff, affecting the entire building.
This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1).
Findings include, but are not limited to:
1. On 5/5/2015, during record review between 9:00 a.m. and 5:00 p.m., the disaster plan provided by the facility to the surveyor did not have a facility map showing the physical locations of utility shutoffs (electric, gas, water, etc.) in the event the utilities needed to be shut down during/after an emergency event.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to provide fire drills for all staff affecting the entire building.
This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents 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 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., facility documentation presented to the surveyor showed that fire drills for day shift in 2014 and 2015 were not being staggered throughout the entire shift. Fire drills were conducted between 8:56 a.m. to 9:29 a.m.
2. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., facility documentation presented to the surveyor showed that fire drills for swing shift in 2014 and 2015 were not being staggered throughout the entire shift. Fire drills were conducted between 8:00 p.m. to 8:25 p.m.
3. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., facility documentation presented to the surveyor showed that fire drills for night shift in 2014 and 2015 were not being staggered throughout the entire shift. Fire drills were conducted between 12:30 a.m. and 1:58 a.m.
4. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such but not limited to number of simulated evacuated patients, specific location of simulated fire, specific type of fire simulated, staff performance and time to completed simulated evacuation of occupants within the affected smoke compartment to an unaffected smoke compartment.
Operating Engineer stated that staff do not simulate the evacuation of patients and staff were silencing fire alarm to reduce the impact to patients and not letting the fire alarm sound during the entire fire drill. Fire drill that was conducted on 12/3/2014 on the 4th floor noted that Nuclear Medicine Staff refused to participate in the drill. All staff must participate in all Fire Drills within the facility.
Fire drill form dated 2/26/2014 noted that Clinical Nurse Manager did not have access to two Physician Sleep Rooms on Floor 3 and was unable to check rooms for occupancy. Fire drill documentation also states that 50% of drills shall be unannounced when all drills shall be unannounced.
5. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., Code Red-Fire Policy instructs the placement of towels or pillows at the foot of the Patient Rm. doors after Patient Rm's. have been evacuated. The placement of pillow or towels at the base of doors within the corridors create an obstruction during relocation of other patients on the floor and would provide combustible materials within the corridor.
Policy also states the it was up to the desecration of the Charge Nurse on removing patients from the affected smoke compartment to an unaffected smoke compartment.
6. On 5/7/2015, at 1:51 p.m., a fire drill was conducted by the surveyors and the following observations were noted: Staff did not clear the corridors in the affected smoke compartment or adjoining unaffected smoke compartments, no simulated evacuation of patients from the affected smoke compartment to the unaffected smoke compartment, no staff communication or leadership, fire alarm pull station was not activated, fire alarm system did not function (not initiated by staff), staff were complacent and some staff continued to work at their computers.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Engineering Staff that the facility failed to provide fire drills for all staff affecting the entire building.
This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents 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 5/5/2015, during record review between 6:30 a.m. and 8:30 a.m., fire drill documentation presented to the surveyor showed that fire drills for day, swing and night shifts were not being staggered.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Staff that the facility failed to install fire alarm system in accordance with NFPA 72 "private mode" systems.
This resulted in the potential for delay and panic during fire emergencies (LSC 19.3.4, 9.6).
Findings include, but are not limited to:
1. On 5/5/2015, at 1:58 p.m., the breakers for the Fire Alarm Control Panel were not labeled with a red "FACP" label.
2. On 5/5/2015, at 1:58 p.m., the breakers for the Fire Alarm Control Panel did not have mechanical set screw locks installed on the breakers.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to test and maintain fire alarm in accordance with NFPA 72 for the entire building.
This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72).
Findings include, but are not limited to:
1. On 5/5/2015, during record review between 8:00 a.m. and 5:00 p.m., monthly and quarterly testing and maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the fire alarm system to the adopted 1999 edition of NFPA 72 standards.
2. On 5/7/2015, at 8:14 a.m., there was a smoke detector within Patient Rm. 302 that had come loose from the ceiling.
3. On 5/7/2015, at 9:15 a.m., there was a missing red "FACP" label next to the breaker controlling the buildings fire alarm control panel.
4. On 5/7/2015, at 9:15 a.m., there was a missing mechanical set screw lock on the electrical breaker controlling the main Fire Alarm Control Panel.
5. On 5/7/2015, at 9:15 a.m., there was missing signage on the main Fire Alarm Control Panel identifying the location and breaker number of the Fire Alarm Control Panel.
6. On 5/7/2015, at 9:17 a.m., there were missing door signage (FACP or Fire Alarm Control Panel) for door B808 and B005 to help responding personnel in locating the fire alarm control panel.
7. On 5/7/2015, at 11:08 a.m., there was a fire alarm pull station that was blocked or obstructed by a cabinet within the Laboratory adjacent to door 1516.
8. On 5/8/2015, at 10:46 a.m., the notification devices for the fire alarm system within the building were observed not be synchronized for floor 4 and 5. This condition was observed during a fire drill by the surveyors as they stood near a main bank of elevators for the facility.
9. On 5/8/2015, at 1:00 p.m., there was a fire alarm pull station that was installed more then 60" from the finish floor to the operating handle within Foyer 2012A adjacent to door S-203.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator 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 5/6/2015, at 5:34 a.m., there was missing automatic sprinkler protection within OR #1, OR #2, OR #3, OR #4, OR #5, OR #6 and OBOR Delivery Rm. #2.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Staff that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition for the 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 5/5/2015, at 3:02 p.m., the automatic sprinkler head had dropped from the ceiling creating a hole into the attic space within the Storage Supply Room adjacent to Occupational Therapy.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to ensure the sprinkler system was 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 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., weekly, monthly, and quarterly testing and maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the sprinklers to the adopted 1998 edition of NFPA 25 standards.
2. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., monthly testing and maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the facilities fire pump to the adopted 1998 edition of NFPA 25 standards.
3. On 5/6/2015, during record review between 8:00 a.m. and 5:00 p.m., there was no integrity testing information for the fixed fire protection system that was located within the Verizon Equipment Room. The "silence" button for this system was not functioning when tested.
4. On 5/6/2015, during the facility tour between 5:30 a.m. and 11:00 a.m., there were missing escutcheon plates on automatic sprinkler heads within the Central Processing Decontamination area and Rm. 2818 in the 7th Avenue Bldg.
5. On 5/6/2015, during the facility tour between 5:30 a.m. and 11:00 a.m., there were damaged automatic sprinkler heads that need to be replaced within the Sterile Processing Clean Side area above the first pass through window and Soiled Utility (Rm 2401) in the 7th Avenue Bldg.
6. On 5/6/2015, at 8:44 a.m., the packing nut on the Standpipe valve located on the roof of the the East Center was loose.
7. On 5/7/2015, during the facility tour between 8:30 a.m. and 12:00 p.m., there were painted automatic sprinkler heads, that need to be replaced, within the Riser Room on the 2nd floor adjacent to Rm. 2104, Rm. B507 and Restroom of the Physician Lounge on Floor 1.
8. On 5/7/2014, during the facility tour between 8:30 a.m. and 12:00 p.m., there were damaged automatic sprinkler heads, that need to be replaced, within the corridor adjacent to Rm. 2228 and Restroom 1188.
9. On 5/7/2015, during the facility tour between 8:30 a.m. and 12:00 p.m., there were missing escutcheon plates on automatic sprinkler heads within the ICU Physical Documentation room, Dish Rm. (near south wall) and Rm. 2352.
10. On 5/7/2015, at 9:53 a.m., the Anti-Freeze Sprinkler Loop for the East Carport shows signs of leaking and corrosion on the control valve. System was located in Rm. 2357.
11. On 5/7/2015, at 10:50 a.m., there was a corroded automatic sprinkler head, that needs to be replaced, within the Walk-In Refrigerator within the Main Kitchen.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to maintain fire extinguishers in accordance with adopted standards for the facility.
This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10).
Findings include, but are not limited to:
1. On 5/6/2015, at 11:30 a.m., there was a missing minimum 10A 120B rated fire extinguisher (Aircraft measured between 50' - 80') for the facilities rooftop Helistop. Fire extinguisher present at the rooftop was only a 4A 60B:C sized extinguisher.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Staff that the facility failed to maintain fire extinguishers in accordance with adopted standards for the facility.
This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10).
Findings include, but are not limited to:
1. On 5/5/2015, at 1:55 p.m., there was a fire extinguisher within the boiler room that was not properly mounted as evidence of the extinguisher sitting on the floor.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to install/maintain an approved ventilation hood and duct system.
This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 4.6.12.1, 9.2.3, 19/18.3.2.6, NFPA 96 A.1.1.4, UL300).
Findings include, but are not limited to:
1. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., Simplex Grinnell (3rd party vendor) noted on their annual inspection report that the Cafe Hood was only 15" from the cooking surface and not the required 18" from the cooking surface and the hood was not a UL300 listed hood.
2. On 5/7/2015, at 10:56 a.m., the cooking surface and fryer within the cafe did not have adequate separation or an adequate baffle plate between the two cooking devices.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator 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 of the building.
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 5/6/2015, at 10:51 a.m., there were wall mounted computer terminals/charting stations that would not close and retract fully to a closed position when opened and released. Terminals and stations were adjacent to Pt. Rm. 5523 and Pt. Rm. 5537.
2. On 5/7/2015, at 10:00 a.m., there were shielding devices for the Nuclear Medicine area that were stored within the egress corridor outside door B417 which created a corridor obstruction within the constructed clear width.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Staff that the facility failed to ensure that no curtains of highly flammable character were used in the building.
This resulted in the potential for excessive fire spread (LSC 19.7.5.1).
Findings include, but are not limited to:
1. On 5/5/2015, during the facility tour between 8:30 a.m. and 3:30 p.m., there were non -fire treated quilts hanging on the walls within the corridors and conference rooms throughout the facility including but not limited to: Social Work Conference Room, Conference Rm. 1 & 3 and corridor outside of Conference Rm's.

Based on observations and interviews it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to provide safe storage for compressed gas.
This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks. (LSC 19.3.2.4, NFPA 99 4.3.1.1.2).
Findings include, but are not limited to:
1. On 5/7/2015, at 9:40 a.m., there were compressed gas cylinders being stored within Rm. B707 (Respiratory Therapy Storage) that had electrical switches and outlets within 60" of the finish floor.
2. On 5/7/2015, at 10:58 a.m., there were compressed gas cylinders that were not properly secured by evidence of the cylinders of a single chain near the top of the cylinders that would allow the bottoms of the cylinders to kick out and strike other cylinders or walls within the exterior LOX storage area during a seismic event.
3. On 5/7/2015, at 10:58 a.m., there were 5-compressed gas cylinders that were not properly secured by evidence of the cylinders standing in a free non-restrained fashion that would allow the cylinders to fall and strike other cylinders or walls within the exterior LOX storage area during a seismic event.

Based on record review and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator 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 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., documentation provided to the surveyor showed that outlets, shutoff valves, flexible connectors, automatic pressure switches and master signal panels were being inspected and maintained by staff and staff did not have technician competence in maintaining the piped medical gas system for the facility.

Based on record review and interviews during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1.
This resulted in the potential for injury to patients during medical procedures.
Findings include, but are not limited to:
1. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., the humidity policy provided by staff only provided guidelines on what to do in the event that the humidity was greater then 70%.
Policy states that humidity shall be maintained between 20% and 70% and Humidity logs show the humidity range to be between 30% and 70%. Humidity logs provided to the surveyor showed humidity levels less than 30% on the following days: OR #1 on 2/5-7/2014, 2/10/2014, 11/11-12/2014, 11/17/2014, 12/30-31/2014, 2/17/2015 and 2/23/2015; OR #2 on 2/4-7/2014, 2/10/2014, 11/11-13/2014, 11/17-18/2014, 12/1/2014, 12/30-31/2014, 1/2/2015, 2/23-24/2015 and 3/4/2015; OR #3 on 1/6/2014, 1/24/2014, 2/4-7/2014, 2/10/2014, 2/26/2014, 11/11-13/2014, 11/17-19/2014, 12/1/2014, 12/3/2014, 12/30-31/2014, 1/2/2015, 2/23-24/2015 and 3/4/2015; OR #4 on 2/4-7/2014, 2/10/2014, 11/11-13/2014, 11/17-18/2014, 12/1/2014, 12/30-31/2014 and 2/23/2015; OR #6 on 2/5-7/2014, 2/10/2014, 11/11-13/2014, 11/17-18/2014, 12/30-31/2014 and 2/23/2015; OR #7 on 1/6/2014, 2/6-7/2014, 2/10/2014, 11/11-13/2014, 11/17-19/2014, 12/1-3/2014, 12/30-31/2014, 1/2/2015 and 2/21/2015.
2. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., there were no humidity logs being kept for the TOPS OR's within the 7th Street Building and the "Humidity Watch Policy" only addressed what to do or who to contact in the event that the humidity was greater than 70%.

Based on observations and interviews it was determined, through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to properly store building service equipment for the building.
This resulted in the potential for unexpected fire (LSC 19.5.2.1, 19.5.2.2, 9.2, NFPA 90A).
Findings include, but are not limited to:
1. On 5/7/2015, at 10:55 a.m., there was a propane barbeque grill with a propane tank connected to the barbeque stored within the kitchen of the facility under a Type II Hood system.

Based on observations, record review and interviews it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to properly maintain the generator affecting the entire facility.
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 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., documentation provided by the facility showed only 2-hr. load bank tests (3/2013 and 4/2013) for both generators and not the required 3-year, 4-hour, minimum 80% nameplate load bank test.
2. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., documentation provided by the facility showed that weekly Electrolyte and monthly Specific Gravity test were not being completed because the generators were equipped with maintenance free batteries.
3. On 5/5/2015, at 11:23 a.m., there was no emergency stop button installed outside the generator enclosure for both generators.

Based on observations, record review and interviews it was determined through on-going dialog with the Engineering Staff that the facility failed to properly maintain the generator affecting the entire facility.
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 5/5/2015, at 1:57 p.m., batteries for the generator were observed to be maintenance free batteries. Facility staff cannot conduct required weekly and monthly maintenance and testing on the generator batteries.
2. On 5/5/15, during record review between 6:30 a.m. and 8:30 a.m., documentation provided to the surveyor showing the required 3-year, 4-hour load bank test was not completed correctly according to NFPA 110 standards as it was conducted at a percentage of the nameplate lower then what was required.

Based on record review and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to provide an alternate source of power in accordance with NFPA 99 3.6, which would provide a minimum of 90 minutes of power in an outage.
This resulted in the potential for panic and confusion for staff and residents in a power outage.
Findings include, but are not limited to:
1. On 5/5/2015, during record review between 11:30 a.m. and 5:30 p.m., there was no documentation provided showing the required monthly or quarterly maintenance and inspection on the Stored Electrical Emergency Power System and staff did not have technician competence in maintaining the system to the adopted 1996 edition of NFPA 111 standards.

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Manager and Ancillary Services Administrator that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for the building.
This resulted in the potential for injury to residents & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 5/6/2015, at 5:44 a.m., there was a broken electrical outlet within OR #5.
2. On 5/6/2015, at 8:52 a.m., there was an open electrical junction box within Penthouse "C" above switch EF-1A.
3. On 5/6/2015, at 10:09 a.m., there was an electrical cord to a black light that was attached to the wall and routed around a ceiling tile within Tuality Health Alliance Office, 6th floor.
4. On 5/7/2015, during the facility tour between 9:00 a.m. and 1:00 p.m., there were missing electrical outlet covers on outlets within Rm. 2101, Rm. 2209 and Rm. 2210.
5. On 5/7/2015, at 9:08 a.m., there was a electrical transformer that showed signs of overheating by discoloration within the Phone Rm. (Door B808) adjacent to the main Fire Alarm Control Panel.
6. On 5/7/2015, at 9:17 a.m., there were exposed non-energized electrical wires from an old clock wall mount within Rm. 2117.
7. On 5/7/2015, at 9:58 a.m., there was a broken GFI electrical outlet within the Soiled Utility Room of Day Surgery.
8. On 5/7/2015, during the facility tour between 9:00 a.m. and 1:00 p.m., there were relocatable power taps (RPT's) on the floor within the following locations but not limited to: RT Office/Charting Area, B113, B420, B104, B209, B305 Pharmacy, B404 Purchasing, Laboratory and B609.
9. On 5/7/2015, during the facility tour between 9:00 a.m. and 1:00 p.m., there were relocatable power taps (RPT's) within patient treatment/care areas that were not UL60601-1 listed. RPT's observed in the following areas but not limited to: B420, B413, Injection Area, Rapid Care Unit Rm. #4 and Nuclear Medicine.
10. On 5/7/2015, during the facility tour between 9:00 a.m. and 1:00 p.m., there were relocatable power taps that were "daisy chained" together within room B113 and Library Manager's Office.
11. On 5/7/2015, at 10:25 a.m., there was a household grade microwave within the Housekeeping Breakroom (B120).

Based on observations and interview during the survey, it was determined through on-going dialog with the Engineering Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for the building.
This resulted in the potential for injury to residents & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 5/5/2015, at 2:02 p.m., there was a broken electrical outlet cover adjacent to the headboard of Bed #2 within the Emergency Department.
2. On 5/5/2015, at 2:02 p.m., there was a missing electrical outlet cover and a half cover installed on a 4x4 junction box within the ITF Room.
3. On 5/5/2015, at 2:14 p.m., there was a power supply for the monitor located within the corridor of the Negative Pressure Room that was routed through the corridor wall from an electrical outlet inside the room.
4. On 5/5/2015, at 3:24 p.m., there was an open electrical junction box on the facility side of the 2-hour separation with the attached Dialysis Center.