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Based on observations and interview it was determined that the facility failed to ensure that smoke separations were maintained as required by 2000 NFPA 101, 19.3.6.2.1. This resulted in the potential for smoke to spread throughout the facility, putting staff and patients at risk. Findings include, but are not limited to:

During a tour of the facility on March 6, 2012 from 3:00 pm to 8:00 pm, smoke barriers were found to be unsealed around two conduits and a fire sprinkler pipe penetration above the tile ceiling in the corridor near the Sleeping Suite, and at four corners of drywall above the tile ceiling in the corridor at the ER and OR Suites.

Surveyor was accompanied by Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged that the walls were not sealed properly in these areas.

Based on record review and observation it was determined that that the facility failed to ensure that corridor doors were maintained as required by 1999 NFPA 80, 2-1.3, 2000 NFPA 101, 4.6.12.4. This resulted in the potential for smoke to travel beyond compartments, posing a risk to staff and patients. Findings include, but are not limited to:

During a review of records on March 6, 2012 from 10:00 am to 3:00 pm, the facility did not have access to the standard NFPA 80 (1999) to properly maintain the fire and smoke doors.

On March 6, 2012 at 7:47 pm, the door separating Patient Room 107 from the corridor had a gap between the top of the door and the jamb.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged the existence of these conditions.

Based on observations and interview it was determined that the facility failed to properly sign doors to the exterior to indicate if they were a designated exit as required by 2000 NFPA 101, 7.10.8.1. This resulted in the potential to cause panic and confusion if occupants exited into a courtyard. Findings include, but are not limited to:

On March 6, 2012 at 7:36 pm, a door leading to the West Rose Garden was not signed to indicate that it was not an exit.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged that the exterior door did not lead to a safe area away from the building.

Based on observations and interview it was determined the facility failed to ensure that exit discharges were illuminated as required by 2000 NFPA 7.8. This resulted in the potential for injury and confusion for occupants exiting the building. Findings include, but are not limited to:

On March 6, 2012 at 4:42 pm, there was no exterior lighting provided outside the West Basement exit.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged that there were no lighting fixtures illuminating the basement exit path.

Based on observations and interview it was determined that the facility failed to install battery-powered emergency lighting in procedure areas as required by 1999 NFPA 99, 3-2.4.2. This resulted in the potential for injury to patients if lighting suddenly failed during a procedure. Findings include, but are not limited to:

On March 6, 2012 at 5:15 pm, there were no battery power lights installed in the Procedure Room, OR 1 or OR 2.

Surveyor was accompanied by the Facilities Manager, who acknowledged that the lights installed in these areas were not on a battery backup.

Based on record review and interview it was determined that the facility failed to create plans for specific disasters as required by 1999 NFPA 99, 11-5. This resulted in the potential for a delay in staff response in an emergency, exposing staff and patients to harm. Findings include, but are not limited to:

During a review of records on March 6, 2012 from 10:00 am to 3:00 pm, the facility's disaster manual did not include plans for specific disasters with directions on how staff should respond. The plans indicated that a response to emergencies would be coordinated by an overhead team, which would be activated after a disaster occurred.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who indicated that the plans simplified response for disasters outside of facility vs. inside the facility. They acknowledged that the disaster manual did not include expectations for responses during a disaster.

Based on record review and observation, it was determined that the facility failed to ensure that the fire alarm system was maintained as required in 1999 NFPA 72, 1-5.2.5.2, 7-1.2.2, 2000 NFPA 101, 4.6.12.4, 9.6, 9.6.3.7. This resulted in the potential for failure of the fire alarm system or devices during an emergency. Findings include, but are not limited to:

During a review of records on March 6, 2012 from 10:00 am to 3:00 pm, the facility did not have documentation of competency for staff performing weekly and monthly maintenance on the fire alarm system. The facility also did not have access to the maintenance standard for fire alarm systems, 1999 NFPA 72.

During a tour of the facility on March 6, 2012 from 3:00 pm to 8:00 pm, the electrical breaker serving the fire alarm system was not identified at the fire alarm control panel, there was not an audible notification device installed in the ED Sleeping Room and there was a strobe device improperly installed in the bathroom of Patient Room 110.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged the above conditions existed. A subsequent e-mail from the Director of Safety on 3/8/12 indicated that the audible signal in the sleeping rooms measured between 69-71 decibels.

Based on record review and interview it was determined that the facility failed to ensure that staff was properly trained to perform maintenance on the fire sprinkler system as required by 1998 NFPA 25, 1-4.2. This resulted in the potential for systems to maintained incorrectly. Findings include, but are not limited to:

On March 6, 2012 at 10:00 am, a review of the facility's records indicated that staff performing maintenance on the fire sprinkler system did not have documentation indicating technician competence. Staff also did not have access to 1998 NFPA 25 to perform weekly and monthly maintenance on the system.

On March 6, 2012 at 10:00 am, the Facilities Services Manager stated that he and his staff did not have documentation to indicate technician competence to perform maintenance on the fire sprinkler system.

Based on observation and interview it was determined that the facility failed to ensure that the fire sprinkler system was maintained in accordance with 1998 NFPA 25, 2-2.1.1, 1999 NFPA 13, 3-2.9, 5-6.3.4, 5-15.2.3.5. This resulted in the potential for a failure of the fire sprinkler system if a head failed to operate or the fire department connected to the FDC. Findings include, but are not limited to:

During a tour of the facility on March 6, 2012 from 4:30 to 8:00 pm, painted or improperly placed fire sprinkler heads were found in the Clean Core of the OR Suite, in the Orthopedic Supply Closet, CNO Office, Shower Room outside of the Utility/Rec Room and Patient Rooms 109 and 111.

On March 6, 2012 at 4:52 pm, there were no spare sidewall fire sprinkler heads in the spare head box in the Basement.

On March 6, 2012 at 5:45 pm, the FDC serving the portion of the building housing the Emergency Department was not signed "FDC" and did not indicate the portion of the facility that it served.

Surveyor was accompanied by the Facilities Services Manager and Director of Safety who acknowledged that the above conditions existed.

Based on record review, observations and interview it was determined that the facility failed to ensure that fire extinguishers were properly placed and maintained in the facility as required by 2000 NFPA 101, 4.6.12.4, 1995 NFPA 418, 5-1. This resulted in the potential for a fire to spread due to improper extinguisher coverage. Findings include, but are not limited to:

During a review of records on March 6, 2012 from 10:00 am to 3:00 pm, the facility did not have access to the standard NFPA 10, 1998 edition, to perform monthly maintenance on the facility's fire extinguishers.

On March 6, 2012 at 6:22 pm, a fire extinguisher was missing at the heliport serving the air medical transport.

Surveyor was accompanied by the Facility Services Director and the Director of Safety, who acknowledged that the standard was not available for reference and that the heliport did not have a fire extinguisher nearby.

Based on observations and interview it was determined that the facility failed to ensure that exit corridors were maintained as required by 2000 NFPA 101, 19.2.3.3, S&C 10-18 LSC. This resulted in the potential for evacuations to be delayed during an emergency. Findings include, but are not limited to:

On March 6, 2012 at 7:35 pm, a water fountain installed in the corridor in the Med/Surg area projected more than six-inches into the 8-foot corridor.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged that the fountain obstructed the corridor width.

Based on observations and interview it was determined that the facility failed to ensure that compressed gas cylinders were properly secured. This resulted in the potential for the tank to tip over and possibly rupture, causing harm to occupants nearby. Ref. NFPA 55, 1998 Edition Section 6-6. Findings include, but are not limited to:

On March 6, 2012 at 7:27 pm, a helium tank in the Gift Shop was not secured in either a rack or by two chains attached to a wall.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged that the tank could fall over as placed.

Based on record review, observations and interview it was determined that the facility failed to ensure that medical gas equipment was properly installed as required by 1999 NFPA 99, 4-3.5.4.2, 8-6.2.5.2. This resulted in the potential for an emergency involving the medical gas system to accelerate due to improper installation. Findings include, but are not limited to:

During a review of records on March 6, 2012 from 10:00 am to 3:00 pm, the annual medical gas certification report from 2010 indicated that there were multiple zone valve boxes that did not indicate area served.

On March 6, 2012 at 5:08 pm, the zone valves for the PACU, OR 1 and OR 2 were not marked with the areas they served.

Surveyor was accompanied by the Facility Services Director, who acknowledged that the valves were not marked.

On March 6, 2012 at 5:50 pm, there was no containment curb installed at the liquid oxygen tank in the parking lot. The driveway was made of asphalt and was sloped downhill to a stormwater drain. Ref. NFPA 50, 1996 Edition, Section 2-1.4.

Surveyor was accompanied by the Facility Services Director and the Director of Safety, who acknowledged that a release of liquid oxygen could come into contact with the surrounding asphalt, creating a chemical reaction resulting in a fire.

Based on record review and interview it was determined that the facility failed to ensure that the emergency generator was being maintained as required by 1999 NFPA 110, 6-3.6, 2000 NFPA 101, 4.6.12.4. This resulted in the potential for the generator to fail during an emergency. Findings include, but are not limited to:

During a review of records on March 6, 2012 from 10:00 am to 3:00 pm, the facility did not have access to the standard NFPA 110 (1999) to perform weekly and monthly maintenance on the emergency generator. The facility was not documenting the electrolyte levels of the batteries weekly in the level 1 emergency generator.

Surveyor was accompanied by the Facility Services Director, Director of Support Services, Director of Safety and Plant Electrician, who acknowledged the existence of the above conditions. The Plant Electrician stated that he checked the water level of the batteries serving the emergency generator monthly.

Based on observations and interview it was determined the facility failed to ensure that appliances were used as listed. This resulted in improper use, potentially causing overheating and fire. Findings include, but are not limited to:

During a tour of the facility on March 6, 2012 from 3:00 pm to 8:00 pm, household-use microwaves were found in the OR Break Room and Dining Room.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged that the microwaves found were rated for household use.

Based on observations and interview it was determined the facility failed to ensure that flexible cords were not used in lieu of permanent wiring as required by 1999 NFPA 70, 400-8. This resulted in the potential for cords to overheat, possibly causing a fire. Findings include, but are not limited to:

During a tour of the facility on March 6, 2012 from 3:00 pm to 8:00 pm, relocatable power taps (RPT) were found in lieu of permanent wiring in the following locations: Three RPTs were found in use in the OR Doctor's Office, two interconnected patient-rated RPTs were found interconnected in the ER by Trauma A, two interconnected RPTs were found serving the fish tank in the Lobby with corrosion, two RPTs were found serving computers in the Admitting area, three RPTs were found interconnected in the Radiologist's Office, RPTs were found serving computers in the Radiologist's Office, Respiratory Therapist's Office and in Mammography.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged the use of relocatable power taps in these areas.

Based on observations and interview it was determined the facility failed to ensure that appliances were plugged directly into an electrical outlet as required by 1999 NFPA 72, 400-7. This resulted in the potential for cords to overheat, possibly causing a fire. Findings include, but are not limited to:

During a tour of the facility on March 6, 2012 from 3:00 pm to 8:00 pm, refrigerators were found plugged into a relocatable power tap in the ER, Nursing Staff Breakroom and IT Office.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged the refrigerators were not plugged directly into an electrical outlet.

Based on observations and interview it was determined that the facility failed to ensure that smoke separations were maintained as required by 2000 NFPA 101, 19.3.6.2.1. This resulted in the potential for smoke to spread throughout the facility, putting staff and patients at risk. Findings include, but are not limited to:

During a tour of the facility on March 6, 2012 from 3:00 pm to 8:00 pm, smoke barriers were found to be unsealed around two conduits and a fire sprinkler pipe penetration above the tile ceiling in the corridor near the Sleeping Suite, and at four corners of drywall above the tile ceiling in the corridor at the ER and OR Suites.

Surveyor was accompanied by Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged that the walls were not sealed properly in these areas.

Based on record review and observation it was determined that that the facility failed to ensure that corridor doors were maintained as required by 1999 NFPA 80, 2-1.3, 2000 NFPA 101, 4.6.12.4. This resulted in the potential for smoke to travel beyond compartments, posing a risk to staff and patients. Findings include, but are not limited to:

During a review of records on March 6, 2012 from 10:00 am to 3:00 pm, the facility did not have access to the standard NFPA 80 (1999) to properly maintain the fire and smoke doors.

On March 6, 2012 at 7:47 pm, the door separating Patient Room 107 from the corridor had a gap between the top of the door and the jamb.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged the existence of these conditions.

Based on observations and interview it was determined that the facility failed to properly sign doors to the exterior to indicate if they were a designated exit as required by 2000 NFPA 101, 7.10.8.1. This resulted in the potential to cause panic and confusion if occupants exited into a courtyard. Findings include, but are not limited to:

On March 6, 2012 at 7:36 pm, a door leading to the West Rose Garden was not signed to indicate that it was not an exit.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged that the exterior door did not lead to a safe area away from the building.

Based on observations and interview it was determined the facility failed to ensure that exit discharges were illuminated as required by 2000 NFPA 7.8. This resulted in the potential for injury and confusion for occupants exiting the building. Findings include, but are not limited to:

On March 6, 2012 at 4:42 pm, there was no exterior lighting provided outside the West Basement exit.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged that there were no lighting fixtures illuminating the basement exit path.

Based on observations and interview it was determined that the facility failed to install battery-powered emergency lighting in procedure areas as required by 1999 NFPA 99, 3-2.4.2. This resulted in the potential for injury to patients if lighting suddenly failed during a procedure. Findings include, but are not limited to:

On March 6, 2012 at 5:15 pm, there were no battery power lights installed in the Procedure Room, OR 1 or OR 2.

Surveyor was accompanied by the Facilities Manager, who acknowledged that the lights installed in these areas were not on a battery backup.

Based on record review and interview it was determined that the facility failed to create plans for specific disasters as required by 1999 NFPA 99, 11-5. This resulted in the potential for a delay in staff response in an emergency, exposing staff and patients to harm. Findings include, but are not limited to:

During a review of records on March 6, 2012 from 10:00 am to 3:00 pm, the facility's disaster manual did not include plans for specific disasters with directions on how staff should respond. The plans indicated that a response to emergencies would be coordinated by an overhead team, which would be activated after a disaster occurred.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who indicated that the plans simplified response for disasters outside of facility vs. inside the facility. They acknowledged that the disaster manual did not include expectations for responses during a disaster.

Based on record review and observation, it was determined that the facility failed to ensure that the fire alarm system was maintained as required in 1999 NFPA 72, 1-5.2.5.2, 7-1.2.2, 2000 NFPA 101, 4.6.12.4, 9.6, 9.6.3.7. This resulted in the potential for failure of the fire alarm system or devices during an emergency. Findings include, but are not limited to:

During a review of records on March 6, 2012 from 10:00 am to 3:00 pm, the facility did not have documentation of competency for staff performing weekly and monthly maintenance on the fire alarm system. The facility also did not have access to the maintenance standard for fire alarm systems, 1999 NFPA 72.

During a tour of the facility on March 6, 2012 from 3:00 pm to 8:00 pm, the electrical breaker serving the fire alarm system was not identified at the fire alarm control panel, there was not an audible notification device installed in the ED Sleeping Room and there was a strobe device improperly installed in the bathroom of Patient Room 110.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged the above conditions existed. A subsequent e-mail from the Director of Safety on 3/8/12 indicated that the audible signal in the sleeping rooms measured between 69-71 decibels.

Based on record review and interview it was determined that the facility failed to ensure that staff was properly trained to perform maintenance on the fire sprinkler system as required by 1998 NFPA 25, 1-4.2. This resulted in the potential for systems to maintained incorrectly. Findings include, but are not limited to:

On March 6, 2012 at 10:00 am, a review of the facility's records indicated that staff performing maintenance on the fire sprinkler system did not have documentation indicating technician competence. Staff also did not have access to 1998 NFPA 25 to perform weekly and monthly maintenance on the system.

On March 6, 2012 at 10:00 am, the Facilities Services Manager stated that he and his staff did not have documentation to indicate technician competence to perform maintenance on the fire sprinkler system.

Based on observation and interview it was determined that the facility failed to ensure that the fire sprinkler system was maintained in accordance with 1998 NFPA 25, 2-2.1.1, 1999 NFPA 13, 3-2.9, 5-6.3.4, 5-15.2.3.5. This resulted in the potential for a failure of the fire sprinkler system if a head failed to operate or the fire department connected to the FDC. Findings include, but are not limited to:

During a tour of the facility on March 6, 2012 from 4:30 to 8:00 pm, painted or improperly placed fire sprinkler heads were found in the Clean Core of the OR Suite, in the Orthopedic Supply Closet, CNO Office, Shower Room outside of the Utility/Rec Room and Patient Rooms 109 and 111.

On March 6, 2012 at 4:52 pm, there were no spare sidewall fire sprinkler heads in the spare head box in the Basement.

On March 6, 2012 at 5:45 pm, the FDC serving the portion of the building housing the Emergency Department was not signed "FDC" and did not indicate the portion of the facility that it served.

Surveyor was accompanied by the Facilities Services Manager and Director of Safety who acknowledged that the above conditions existed.

Based on record review, observations and interview it was determined that the facility failed to ensure that fire extinguishers were properly placed and maintained in the facility as required by 2000 NFPA 101, 4.6.12.4, 1995 NFPA 418, 5-1. This resulted in the potential for a fire to spread due to improper extinguisher coverage. Findings include, but are not limited to:

During a review of records on March 6, 2012 from 10:00 am to 3:00 pm, the facility did not have access to the standard NFPA 10, 1998 edition, to perform monthly maintenance on the facility's fire extinguishers.

On March 6, 2012 at 6:22 pm, a fire extinguisher was missing at the heliport serving the air medical transport.

Surveyor was accompanied by the Facility Services Director and the Director of Safety, who acknowledged that the standard was not available for reference and that the heliport did not have a fire extinguisher nearby.

Based on observations and interview it was determined that the facility failed to ensure that exit corridors were maintained as required by 2000 NFPA 101, 19.2.3.3, S&C 10-18 LSC. This resulted in the potential for evacuations to be delayed during an emergency. Findings include, but are not limited to:

On March 6, 2012 at 7:35 pm, a water fountain installed in the corridor in the Med/Surg area projected more than six-inches into the 8-foot corridor.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged that the fountain obstructed the corridor width.

Based on observations and interview it was determined that the facility failed to ensure that compressed gas cylinders were properly secured. This resulted in the potential for the tank to tip over and possibly rupture, causing harm to occupants nearby. Ref. NFPA 55, 1998 Edition Section 6-6. Findings include, but are not limited to:

On March 6, 2012 at 7:27 pm, a helium tank in the Gift Shop was not secured in either a rack or by two chains attached to a wall.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged that the tank could fall over as placed.

Based on record review, observations and interview it was determined that the facility failed to ensure that medical gas equipment was properly installed as required by 1999 NFPA 99, 4-3.5.4.2, 8-6.2.5.2. This resulted in the potential for an emergency involving the medical gas system to accelerate due to improper installation. Findings include, but are not limited to:

During a review of records on March 6, 2012 from 10:00 am to 3:00 pm, the annual medical gas certification report from 2010 indicated that there were multiple zone valve boxes that did not indicate area served.

On March 6, 2012 at 5:08 pm, the zone valves for the PACU, OR 1 and OR 2 were not marked with the areas they served.

Surveyor was accompanied by the Facility Services Director, who acknowledged that the valves were not marked.

On March 6, 2012 at 5:50 pm, there was no containment curb installed at the liquid oxygen tank in the parking lot. The driveway was made of asphalt and was sloped downhill to a stormwater drain. Ref. NFPA 50, 1996 Edition, Section 2-1.4.

Surveyor was accompanied by the Facility Services Director and the Director of Safety, who acknowledged that a release of liquid oxygen could come into contact with the surrounding asphalt, creating a chemical reaction resulting in a fire.

Based on record review and interview it was determined that the facility failed to ensure that the emergency generator was being maintained as required by 1999 NFPA 110, 6-3.6, 2000 NFPA 101, 4.6.12.4. This resulted in the potential for the generator to fail during an emergency. Findings include, but are not limited to:

During a review of records on March 6, 2012 from 10:00 am to 3:00 pm, the facility did not have access to the standard NFPA 110 (1999) to perform weekly and monthly maintenance on the emergency generator. The facility was not documenting the electrolyte levels of the batteries weekly in the level 1 emergency generator.

Surveyor was accompanied by the Facility Services Director, Director of Support Services, Director of Safety and Plant Electrician, who acknowledged the existence of the above conditions. The Plant Electrician stated that he checked the water level of the batteries serving the emergency generator monthly.

Based on observations and interview it was determined the facility failed to ensure that appliances were used as listed. This resulted in improper use, potentially causing overheating and fire. Findings include, but are not limited to:

During a tour of the facility on March 6, 2012 from 3:00 pm to 8:00 pm, household-use microwaves were found in the OR Break Room and Dining Room.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged that the microwaves found were rated for household use.

Based on observations and interview it was determined the facility failed to ensure that flexible cords were not used in lieu of permanent wiring as required by 1999 NFPA 70, 400-8. This resulted in the potential for cords to overheat, possibly causing a fire. Findings include, but are not limited to:

During a tour of the facility on March 6, 2012 from 3:00 pm to 8:00 pm, relocatable power taps (RPT) were found in lieu of permanent wiring in the following locations: Three RPTs were found in use in the OR Doctor's Office, two interconnected patient-rated RPTs were found interconnected in the ER by Trauma A, two interconnected RPTs were found serving the fish tank in the Lobby with corrosion, two RPTs were found serving computers in the Admitting area, three RPTs were found interconnected in the Radiologist's Office, RPTs were found serving computers in the Radiologist's Office, Respiratory Therapist's Office and in Mammography.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged the use of relocatable power taps in these areas.

Based on observations and interview it was determined the facility failed to ensure that appliances were plugged directly into an electrical outlet as required by 1999 NFPA 72, 400-7. This resulted in the potential for cords to overheat, possibly causing a fire. Findings include, but are not limited to:

During a tour of the facility on March 6, 2012 from 3:00 pm to 8:00 pm, refrigerators were found plugged into a relocatable power tap in the ER, Nursing Staff Breakroom and IT Office.

Surveyor was accompanied by the Facility Services Director, Director of Support Services and the Director of Safety, who acknowledged the refrigerators were not plugged directly into an electrical outlet.