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Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff that the facility failed to maintain the integrity of smoke separations. 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 1/28/2016, at 9:48 a.m., there were multiple unsealed ceiling penetrations that ranged in approximate size of 1" in diameter to 2" in diameter within the Boiler Room that would allow products of combustion (smoke and heat) into the attic space of the facility.
2. On 1/28/2016, at 9:50 a.m., there were unsealed ceiling penetrations that ranged in approximate size of 1/2" in diameter to 1" in diameter within the Compressor Room that would allow products of combustion (smoke and heat) into the attic space of the facility.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance 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 (LSC 19.2.3.5, Table 19.3.2.1, 19.3.6.3, Exception 2; A19.3.6.3.3). Findings include, but are not limited to:
1. On 1/27/2016, at 4:28 p.m., the east leaf of the cross-corridor smoke barrier doors adjacent to Patient Rm. #105 and Rm. #106 was not closing and latching properly when tested by the surveyor. Surveyor noted that there was a lot of air movement between the leaf's of these doors not allowing the east leaf to close.
2. On 1/28/2016, at 10:10 a.m., there was a single door leading into the Bone Scanner Room that was part of the smoke barrier and was not closing or latching properly when tested by the surveyor.
3. On 1/28/2016, at 10:14 a.m., there was single door leading into an EVS/Laundry Room that was part of the smoke barrier and was not closing or latching properly when tested by the surveyor.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff that the facility failed to provide two smoke compartments on each floor or fire area in existing buildings (19.3.7.1, 19.3.7.2) and failed to provide two smoke compartments on each floor or fire area for new buildings (18.3.7.1, 18.3.7.2). This resulted in the potential for facility to not be able to use the defend in place concept. Findings include, but are not limited to:
1. On 1/27/2016, at 3:48 p.m., there were multiple unsealed smoke barrier wall penetrations that ranged in size from 3/4" in diameter to 2" in diameter above the cross-corridor doors leading to the Surgery Area that was part of the smoke compartment separation.
2. On 1/27/2016, at 4:25 p.m., there were multiple unsealed smoke barrier wall penetrations that ranged in size from 1" in diameter to 3" in diameter above the cross-corridor doors adjacent to Patient Rm. #105 and #106 that was part of the smoke compartment separation.
3. On 1/28/2016, at 9:32 a.m., there were multiple unsealed smoke barrier wall penetrations that ranged in size from 1" in diameter to 4" in diameter above the cross-corridor doors adjacent to the CT Scan Room that was part of the smoke compartment separation.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff that the facility failed to provide a one hour separation between hazardous areas and corridors of the building. This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 18.3.2, 19.3.2, 8.4). Findings include, but are not limited to:
1. On 1/27/2016, at 4:00 p.m., there was a missing automatic door closure on a Soiled Utility room within the Pre-Op area. Maintenance Staff mentioned that the room was not originally a Soiled Utility Room and that it was converted into a Soiled Utility Room.
2. On 1/28/2016, at 11:05 a.m., there was a missing automatic door closure on a Soiled Utility room within the Emergency Department across from a Patient ED Room.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Staff that the facility failed to provide a one hour separation between hazardous areas and the corridor. This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 38.3.2.1, 8.4). Findings include, but are not limited to:
1. On 1/28/2016, at 2:09 p.m., there was a missing automatic door closure on the Soiled Utility Room door of the facility.

Based on record review and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff 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 patients & staff during emergency evacuation conditions (LSC 19.2.8). Findings include, but are not limited to:
1. On 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., there was no documentation showing the required annual 90 minute test on emergency lights within the facilities Operating Rooms and Procedure Rooms.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff 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 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., the emergency preparedness plan (disaster plan) presented to the surveyor by the facility did not show date of when the entire plan was last reviewed. The plan had phone numbers for contacting OSFM that were not current/correct phone numbers.
2. On 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., the disaster plan provided by the facility to the surveyor did not have a facility map showing the physical location of utility shutoffs (electric, gas, water, etc.) in the event the utilities needed to be shut down during/after an emergency event.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Maintenance Staff 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 38.7). Findings include, but are not limited to:
1. On 1/28/2016, during record review between 1:30 p.m. and 2:00 p.m., the Emergency Preparedness Plan (Disaster Plan) presented to the surveyor for the facility the had no annual review date. Surveyor was unable to determine if the facility disaster plan had been reviewed in the last 12 months.
2. On 1/28/2016, during record review between 1:30 p.m. and 2:00 p.m., the Emergency Preparedness Plan (Disaster Plan) did not have documentation of an annual Hazard Vulnerability Assessment specific to hazards that would be encountered by the facility.
3. On 1/28/2016, during record review between 1:30 p.m. and 2:00 p.m., the Emergency Preparedness Plan (Disaster plan) provided by the facility to the surveyor did not have a facility map showing the physical location of utility shutoffs (electric, gas, water, etc.) in the event the utilities needed to be shut down during/after an emergency event.
4. On 1/28/2016, during record review between 1:30 p.m. and 2:00 p.m., documentation provided by the facility showed only one of two required emergency preparedness drills for a 12 month period of time. Emergency preparedness drills were conducted on 1/2014 and 10/2015.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Maintenance 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 patients to smoke and fire in the facility (LSC 38.7.1. A.38.7.1). Findings include, but are not limited to:
1. On 1/28/2016, during record review between 1:30 p.m. and 2:00 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as but not limited to the number of simulated evacuated occupants from the building, specific location of simulated fire, Staff Performance during the drill and time to complete the simulated evacuation of occupants during the fire drill.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance 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 1/26/2016, during record review between 1:30 p.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 as but not limited to the number of simulated evacuated occupants from the affected smoke compartment to the unaffected smoke compartment, time to conducted the simulated evacuation, specific type of fire simulated, and specific Staff Performance during the drill.
2. On 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., the facility had no documentation on conducting 4th quarter day shift fire drill. Fire drill paperwork showed this as an actual event. Actual events and false alarms cannot be used as Fire drills.
3. On 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., facility documentation presented to the surveyor by the facility showed that fire drills for day shift and night shift in 2013, 2014 and 2015 were not completed under varying conditions and random times throughout the shift. Day shift fire drills were conducted between 2:00 p.m. and 2:40 p.m. and night shift drills were conducted between 7:20 p.m. and 8:00 p.m. which demonstrates that fire drills were conducted in a manner that created a pattern, instead of on different days and times and involving different locations and simulated circumstances.
4. On 1/29/2016, at 9:50 a.m., the surveyor's conducted an unannounced fire drill within the facility. Simulated fire was stated within the smoke compartment that housed the Emergency Department. Facility staff responding to the fire drill did not clear egress corridors from obstructions (housekeeping cart and wheel chairs) and staff did not simulate the evacuation of approximately 14 occupants that could be within the smoke compartment during an actual event. Surveyor asked staff how they simulate the evacuation of patients from the affected smoke compartment to the unaffected smoke compartment and staff mentioned that they would only remove the patient from the fire room. Surveyor questioned other occupants outside of the Emergency Department but within the same smoke compartment and those individuals were not escorted or told to move to another area of the building. The overhead announcement was only heard within certain areas of the hospital as well.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Staff that the facility failed to install fire alarm system in accordance with NFPA 72 " private mode " systems. This resulted in the potential for system and device failure during fire emergencies (LSC 38.3.4, 9.6). Findings include, but are not limited to:
1. On 1/28/2016, at 1:57 p.m., there was a missing required smoke detector that shall be installed above and protecting the Fire Alarm Control Panel, which was located within a closet that was not able to be monitored constantly.
2. On 1/28/2016, at 1:58 p.m., there was not a sign on the door of the storage closet leading to the Fire Alarm Control Panel (FACP). The location for the breaker for the FACP was not identified on the door of the FACP. The electrical panel housing the breaker for the FACP was not labeled in red and did not have a mechanical set screw lock on the breaker.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff 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 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., monthly and quarterly testing and maintenance was being performed by staff and there was no documentation showing that all staff members had technician competence in maintaining the fire alarm system to the adopted 1999 edition of NFPA 72 standards.
2. On 1/27/2016, at 4:22 p.m., there was fire alarm wiring that was not completed professional manner above the hard lid ceiling within the Dress Out Room. The wire was partially in and out of metal conduit.
3. On 1/28/2016, at 10:46 a.m., the set screw lock for the fire alarm control panel electrical breaker was not affixed to the breaker. The lock was laying at the bottom of the electrical panel.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Maintenance Staff that the facility failed to test and maintain fire alarm in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72). Findings include, but are not limited to:
1. On 1/28/2016, during record review between 1:30 p.m. and 2:00 p.m., there was no monthly, quarterly or annual fire alarm documentation being kept on site at the facility. Staff informed surveyor that all information was kept at West Valley Hospital.
2. On 1/28/2016, during record review between 1:30 p.m. and 2:00 p.m., monthly and quarterly inspections on the fire alarm system was not being completed by Maintenance Staff or by a Third Party Vendor as required and outlined in NFPA 72.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff 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 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., weekly, monthly, and quarterly testing and maintenance was being performed by staff and there was no documentation showing that all staff had technician competence in maintaining the sprinklers to the adopted 1998 edition of NFPA 25 standards.
2. On 1/28/2016, at 9:11 a.m., there were mismatched automatic sprinkler heads within the Maintenance Office area. There were quick-response heads mixed with standard response heads.
3. On 1/28/2016, at 9:19 a.m., there was a blocked/obstructed automatic sprinkler by electrical conduit within the Soiled Utility Room adjacent to the Employee Entrance on the east side of the building (Door 22-02).
4. On 1/28/2016, at 9:35 a.m., there was a gap around the automatic sprinkler head within the CT Storage area that would allow products of combustion into the attic space area.
5. On 1/28/2016, at 11:12 a.m., there was an escutcheon plate around the automatic sprinkler head that was not in place within the Staff Restroom within the Rehab area.
6. On 1/28/2016, at 11:35 a.m., there were corroded or painted automatic sprinkler heads within the main exterior overhang (Washington Street side) that shall be replaced.
7. On 1/28/2016, at 3:35 p.m., there were corroded or painted automatic sprinkler heads within the ambulance exterior overhang (Lewis Street side) that shall be replaced.
8. On 1/28/2016, at 3:38 p.m., there was an escutcheon plate around the automatic sprinkler head that was not in place at the double doors leading from the ED to the exterior ambulance entrance/exit.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance 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 1/26/2016, at 4:15 p.m., there was a fire extinguisher within the Conference Room. Fire extinguisher was sitting on a cardboard box and not properly secured/installed to the wall of the facility.
2. On 1/27/2016, at 4:56 p.m., there was no A-rated fire extinguisher within 75' of a common travel path within the Imaging Area of the facility, only a B/C rated fire extinguisher was present.
3. On 1/28/2016, at 10:33 a.m., there was a blocked/obstructed fire extinguisher by a recycle bin within the Main Room of the facility.
4. On 1/28/2016, at 10:40 a.m., there was not a minimum 4A 40B:C fire extinguisher in the kitchen of the facility only a 2A:K fire extinguishers was located.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Staff that the facility failed to maintain fire extinguishers in accordance with adopted standards for all extinguishers of the facility. This resulted in the potential for fires to progress beyond incipient stage (LSC 38.3.5, 9.7.4.1, NFPA 10). Findings include, but are not limited to:
1. On 1/28/2016, at 2:01 p.m., there was a fire extinguisher within the Treatment Area and adjacent to the Nurse Station that was installed to high. The handle for the extinguisher measured 66" of the finish floor and not within the acceptable range of a minimum of 4" of finish floor and maximum of 60" of finish floor.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff that the facility failed to prohibit the use of portable space heating devices. This resulted in the potential for ignition of nearby combustibles (LSC 19.7.8). Findings include, but are not limited to:
1. On 1/28/2016, at 11:32 a.m., there was a space heater within the Access Service Supervisors Office that failed to shutoff when tested/tipped over by the surveyor.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff that the facility failed to provide safe storage for compressed gas cylinders for the facility. This resulted in the potential for injury to staff and residents from a damaged compressed gas cylinder releasing unexpectedly. (LSC 19.3.2.4, NFPA 99 4.3.1.1.2). Findings include, but were not limited to:
1. On 1/27/2016, at 2:30 p.m., there were approximately (8) M-Sized compressed gas cylinders within the LOX area that were not properly secured by evidence of only a single chain near the center of the cylinder that would allow the bottoms of the cylinders to kick out and strike other cylinders or constructed enclosures during a seismic event.
2. On 1/28/2016, at 10:22 a.m., there were (2) M-Sized compressed gas cylinders within the O2 Room that were not properly secured by evidence of only a single chain near the top of the cylinder that would allow the bottoms of the cylinders to kick out and strike other cylinders or walls within in the room during a seismic event.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1 S&C 13-25 LSC, S&C 15-27 LSC. This resulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to:
1. On 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., the humidity policy presented to the surveyor by the facility showed that the adopted humidity range for anesthetizing locations was 20% - 60%. Facility could not provide any documentation or IFU's (instruction's for use) for equipment within these areas to show that the equipment could tolerate the lower range of the adopted humidity level.
2. On 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., facility provide humidity levels documentation and the humidity was measured below 20% on the following dates: 12/10/13, 12/11/13 with no noted notification to Engineering as outlined within the Humidity Policy.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on record review and interviews it was determined through on-going dialog with the Maintenance Director and Maintenance 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 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., monthly maintenance was being performed by staff and there was no documentation showing that all staff had technician competence in maintaining the generator to the adopted 1999 edition of NFPA 110 standards.
2. On 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., there was no documentation provided to the surveyor showing monthly specific gravity checks on the batteries for the emergency power generator.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff 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 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., there was no documentation provided to the surveyor showing the required annual 90 minute test on the battery powered emergency lights for the generator and generator transfer switch room.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to patients & staff (NFPA 70, 9.1.2, NEC 110-3.8). Findings include, but are not limited to:
1. On 1/27/2016, at 3:48 p.m., there was an open electrical junction box above the double doors leading into the Surgery Area.
2. On 1/27/2016, at 4:25 p.m., there was an open electrical junction box above the double doors adjacent to Rm. 105 and Rm. 106.
3. On 1/27/2016, at 4:57 p.m., there was a missing screw on the A/C vent grate within the Men's restroom adjacent to Imaging that allowed the vent grate to sag from the ceiling.
4. On 1/28/2016, at 9:23 a.m., there was a fluorescent light fixture that had broken prongs and missing bulbs within a room adjacent to the Staff Entrance on the east side of the building.
5. On 1/28/2016, at 9:33 a.m., there was a non UL60601-1 listed relocatable power tap in use within the MRI CT Room adjacent to the computers.
6. On 1/28/2016, at 9:40 a.m., there was a live transformer above the ceiling tiles within the CT Room that had wires that were not protected properly.
7. On 1/28/2016, at 10:28 a.m., there was a relocatable power tap on the floor within the Doctor's Sleep Room and Care Managers Office adjacent to the computers.
8. On 1/28/2016, at 10:32 a.m., there was a relocatable power tap on the floor behind the desk within the Epic-IS Room.
9. On 1/28/2016, at 10:35 a.m., there was a relocatable power tap on the floor within the HIM Room.
10. On 1/28/2016, at 11:22 a.m., there was a non UL60601-1 listed relocatable power tap in use within Patient Rehab adjacent to a fitness machine and exterior exit on the south side of the room.
11. On 1/28/2016, at 11:26 a.m., there was a relocatable power tap on the floor within the Computer Training Room.
12. On 1/28/2016, at 11:28 a.m., there was a non UL60601-1 listed relocatable power tap within the Infusion Wound Care Rm. #6 adjacent to the computer.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to patients & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:
1. On 1/28/2016, during the facility tour between 2:00 p.m. and 2:30 p.m., there were non listed UL60601-1 relocatable power taps within the following patient care areas but not limited to the lab draw area (on counter for computer), Exam Rm. #1, Exam Rm. #2, Exam Rm. #3, Exam Rm. #4 and Exam Rm. #5.

Based on the observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff that the facility failed to install alcohol based hand rub (ABHR) dispensers away from sources of ignition. This resulted in the potential for injury to patients and staff (LSC 18.3.2.6, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623). Findings include, but are not limited to:
1. 1/27/2016, at 4:47 p.m., there was an alcohol based hand rube dispenser installed above an electrical outlet within the Radiology/Lab Imaging Waiting Area.
2. On 1/28/2016, at 11:01 a.m., there was an alcohol based hand rub dispenser installed above an electrical light switch at the ED Nurse Station.
3. On 1/28/2016, at 11:15 a.m., there was an alcohol based hand rub dispenser installed above an electrical light switch within Anti-Coag Rm. #2.
4. On 1/28/2016, at 11:26 a.m., there was an alcohol based hand rub dispense installed above an electrical light switch within the Computer Training Room.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff that the facility failed to maintain the integrity of smoke separations. 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 1/28/2016, at 9:48 a.m., there were multiple unsealed ceiling penetrations that ranged in approximate size of 1" in diameter to 2" in diameter within the Boiler Room that would allow products of combustion (smoke and heat) into the attic space of the facility.
2. On 1/28/2016, at 9:50 a.m., there were unsealed ceiling penetrations that ranged in approximate size of 1/2" in diameter to 1" in diameter within the Compressor Room that would allow products of combustion (smoke and heat) into the attic space of the facility.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance 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 (LSC 19.2.3.5, Table 19.3.2.1, 19.3.6.3, Exception 2; A19.3.6.3.3). Findings include, but are not limited to:
1. On 1/27/2016, at 4:28 p.m., the east leaf of the cross-corridor smoke barrier doors adjacent to Patient Rm. #105 and Rm. #106 was not closing and latching properly when tested by the surveyor. Surveyor noted that there was a lot of air movement between the leaf's of these doors not allowing the east leaf to close.
2. On 1/28/2016, at 10:10 a.m., there was a single door leading into the Bone Scanner Room that was part of the smoke barrier and was not closing or latching properly when tested by the surveyor.
3. On 1/28/2016, at 10:14 a.m., there was single door leading into an EVS/Laundry Room that was part of the smoke barrier and was not closing or latching properly when tested by the surveyor.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff that the facility failed to provide two smoke compartments on each floor or fire area in existing buildings (19.3.7.1, 19.3.7.2) and failed to provide two smoke compartments on each floor or fire area for new buildings (18.3.7.1, 18.3.7.2). This resulted in the potential for facility to not be able to use the defend in place concept. Findings include, but are not limited to:
1. On 1/27/2016, at 3:48 p.m., there were multiple unsealed smoke barrier wall penetrations that ranged in size from 3/4" in diameter to 2" in diameter above the cross-corridor doors leading to the Surgery Area that was part of the smoke compartment separation.
2. On 1/27/2016, at 4:25 p.m., there were multiple unsealed smoke barrier wall penetrations that ranged in size from 1" in diameter to 3" in diameter above the cross-corridor doors adjacent to Patient Rm. #105 and #106 that was part of the smoke compartment separation.
3. On 1/28/2016, at 9:32 a.m., there were multiple unsealed smoke barrier wall penetrations that ranged in size from 1" in diameter to 4" in diameter above the cross-corridor doors adjacent to the CT Scan Room that was part of the smoke compartment separation.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff that the facility failed to provide a one hour separation between hazardous areas and corridors of the building. This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 18.3.2, 19.3.2, 8.4). Findings include, but are not limited to:
1. On 1/27/2016, at 4:00 p.m., there was a missing automatic door closure on a Soiled Utility room within the Pre-Op area. Maintenance Staff mentioned that the room was not originally a Soiled Utility Room and that it was converted into a Soiled Utility Room.
2. On 1/28/2016, at 11:05 a.m., there was a missing automatic door closure on a Soiled Utility room within the Emergency Department across from a Patient ED Room.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Staff that the facility failed to provide a one hour separation between hazardous areas and the corridor. This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 38.3.2.1, 8.4). Findings include, but are not limited to:
1. On 1/28/2016, at 2:09 p.m., there was a missing automatic door closure on the Soiled Utility Room door of the facility.

Based on record review and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff 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 patients & staff during emergency evacuation conditions (LSC 19.2.8). Findings include, but are not limited to:
1. On 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., there was no documentation showing the required annual 90 minute test on emergency lights within the facilities Operating Rooms and Procedure Rooms.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff 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 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., the emergency preparedness plan (disaster plan) presented to the surveyor by the facility did not show date of when the entire plan was last reviewed. The plan had phone numbers for contacting OSFM that were not current/correct phone numbers.
2. On 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., the disaster plan provided by the facility to the surveyor did not have a facility map showing the physical location of utility shutoffs (electric, gas, water, etc.) in the event the utilities needed to be shut down during/after an emergency event.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Maintenance Staff 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 38.7). Findings include, but are not limited to:
1. On 1/28/2016, during record review between 1:30 p.m. and 2:00 p.m., the Emergency Preparedness Plan (Disaster Plan) presented to the surveyor for the facility the had no annual review date. Surveyor was unable to determine if the facility disaster plan had been reviewed in the last 12 months.
2. On 1/28/2016, during record review between 1:30 p.m. and 2:00 p.m., the Emergency Preparedness Plan (Disaster Plan) did not have documentation of an annual Hazard Vulnerability Assessment specific to hazards that would be encountered by the facility.
3. On 1/28/2016, during record review between 1:30 p.m. and 2:00 p.m., the Emergency Preparedness Plan (Disaster plan) provided by the facility to the surveyor did not have a facility map showing the physical location of utility shutoffs (electric, gas, water, etc.) in the event the utilities needed to be shut down during/after an emergency event.
4. On 1/28/2016, during record review between 1:30 p.m. and 2:00 p.m., documentation provided by the facility showed only one of two required emergency preparedness drills for a 12 month period of time. Emergency preparedness drills were conducted on 1/2014 and 10/2015.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Maintenance 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 patients to smoke and fire in the facility (LSC 38.7.1. A.38.7.1). Findings include, but are not limited to:
1. On 1/28/2016, during record review between 1:30 p.m. and 2:00 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as but not limited to the number of simulated evacuated occupants from the building, specific location of simulated fire, Staff Performance during the drill and time to complete the simulated evacuation of occupants during the fire drill.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance 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 1/26/2016, during record review between 1:30 p.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 as but not limited to the number of simulated evacuated occupants from the affected smoke compartment to the unaffected smoke compartment, time to conducted the simulated evacuation, specific type of fire simulated, and specific Staff Performance during the drill.
2. On 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., the facility had no documentation on conducting 4th quarter day shift fire drill. Fire drill paperwork showed this as an actual event. Actual events and false alarms cannot be used as Fire drills.
3. On 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., facility documentation presented to the surveyor by the facility showed that fire drills for day shift and night shift in 2013, 2014 and 2015 were not completed under varying conditions and random times throughout the shift. Day shift fire drills were conducted between 2:00 p.m. and 2:40 p.m. and night shift drills were conducted between 7:20 p.m. and 8:00 p.m. which demonstrates that fire drills were conducted in a manner that created a pattern, instead of on different days and times and involving different locations and simulated circumstances.
4. On 1/29/2016, at 9:50 a.m., the surveyor's conducted an unannounced fire drill within the facility. Simulated fire was stated within the smoke compartment that housed the Emergency Department. Facility staff responding to the fire drill did not clear egress corridors from obstructions (housekeeping cart and wheel chairs) and staff did not simulate the evacuation of approximately 14 occupants that could be within the smoke compartment during an actual event. Surveyor asked staff how they simulate the evacuation of patients from the affected smoke compartment to the unaffected smoke compartment and staff mentioned that they would only remove the patient from the fire room. Surveyor questioned other occupants outside of the Emergency Department but within the same smoke compartment and those individuals were not escorted or told to move to another area of the building. The overhead announcement was only heard within certain areas of the hospital as well.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Staff that the facility failed to install fire alarm system in accordance with NFPA 72 " private mode " systems. This resulted in the potential for system and device failure during fire emergencies (LSC 38.3.4, 9.6). Findings include, but are not limited to:
1. On 1/28/2016, at 1:57 p.m., there was a missing required smoke detector that shall be installed above and protecting the Fire Alarm Control Panel, which was located within a closet that was not able to be monitored constantly.
2. On 1/28/2016, at 1:58 p.m., there was not a sign on the door of the storage closet leading to the Fire Alarm Control Panel (FACP). The location for the breaker for the FACP was not identified on the door of the FACP. The electrical panel housing the breaker for the FACP was not labeled in red and did not have a mechanical set screw lock on the breaker.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff 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 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., monthly and quarterly testing and maintenance was being performed by staff and there was no documentation showing that all staff members had technician competence in maintaining the fire alarm system to the adopted 1999 edition of NFPA 72 standards.
2. On 1/27/2016, at 4:22 p.m., there was fire alarm wiring that was not completed professional manner above the hard lid ceiling within the Dress Out Room. The wire was partially in and out of metal conduit.
3. On 1/28/2016, at 10:46 a.m., the set screw lock for the fire alarm control panel electrical breaker was not affixed to the breaker. The lock was laying at the bottom of the electrical panel.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Maintenance Staff that the facility failed to test and maintain fire alarm in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72). Findings include, but are not limited to:
1. On 1/28/2016, during record review between 1:30 p.m. and 2:00 p.m., there was no monthly, quarterly or annual fire alarm documentation being kept on site at the facility. Staff informed surveyor that all information was kept at West Valley Hospital.
2. On 1/28/2016, during record review between 1:30 p.m. and 2:00 p.m., monthly and quarterly inspections on the fire alarm system was not being completed by Maintenance Staff or by a Third Party Vendor as required and outlined in NFPA 72.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff 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 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., weekly, monthly, and quarterly testing and maintenance was being performed by staff and there was no documentation showing that all staff had technician competence in maintaining the sprinklers to the adopted 1998 edition of NFPA 25 standards.
2. On 1/28/2016, at 9:11 a.m., there were mismatched automatic sprinkler heads within the Maintenance Office area. There were quick-response heads mixed with standard response heads.
3. On 1/28/2016, at 9:19 a.m., there was a blocked/obstructed automatic sprinkler by electrical conduit within the Soiled Utility Room adjacent to the Employee Entrance on the east side of the building (Door 22-02).
4. On 1/28/2016, at 9:35 a.m., there was a gap around the automatic sprinkler head within the CT Storage area that would allow products of combustion into the attic space area.
5. On 1/28/2016, at 11:12 a.m., there was an escutcheon plate around the automatic sprinkler head that was not in place within the Staff Restroom within the Rehab area.
6. On 1/28/2016, at 11:35 a.m., there were corroded or painted automatic sprinkler heads within the main exterior overhang (Washington Street side) that shall be replaced.
7. On 1/28/2016, at 3:35 p.m., there were corroded or painted automatic sprinkler heads within the ambulance exterior overhang (Lewis Street side) that shall be replaced.
8. On 1/28/2016, at 3:38 p.m., there was an escutcheon plate around the automatic sprinkler head that was not in place at the double doors leading from the ED to the exterior ambulance entrance/exit.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance 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 1/26/2016, at 4:15 p.m., there was a fire extinguisher within the Conference Room. Fire extinguisher was sitting on a cardboard box and not properly secured/installed to the wall of the facility.
2. On 1/27/2016, at 4:56 p.m., there was no A-rated fire extinguisher within 75' of a common travel path within the Imaging Area of the facility, only a B/C rated fire extinguisher was present.
3. On 1/28/2016, at 10:33 a.m., there was a blocked/obstructed fire extinguisher by a recycle bin within the Main Room of the facility.
4. On 1/28/2016, at 10:40 a.m., there was not a minimum 4A 40B:C fire extinguisher in the kitchen of the facility only a 2A:K fire extinguishers was located.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Staff that the facility failed to maintain fire extinguishers in accordance with adopted standards for all extinguishers of the facility. This resulted in the potential for fires to progress beyond incipient stage (LSC 38.3.5, 9.7.4.1, NFPA 10). Findings include, but are not limited to:
1. On 1/28/2016, at 2:01 p.m., there was a fire extinguisher within the Treatment Area and adjacent to the Nurse Station that was installed to high. The handle for the extinguisher measured 66" of the finish floor and not within the acceptable range of a minimum of 4" of finish floor and maximum of 60" of finish floor.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff that the facility failed to prohibit the use of portable space heating devices. This resulted in the potential for ignition of nearby combustibles (LSC 19.7.8). Findings include, but are not limited to:
1. On 1/28/2016, at 11:32 a.m., there was a space heater within the Access Service Supervisors Office that failed to shutoff when tested/tipped over by the surveyor.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff that the facility failed to provide safe storage for compressed gas cylinders for the facility. This resulted in the potential for injury to staff and residents from a damaged compressed gas cylinder releasing unexpectedly. (LSC 19.3.2.4, NFPA 99 4.3.1.1.2). Findings include, but were not limited to:
1. On 1/27/2016, at 2:30 p.m., there were approximately (8) M-Sized compressed gas cylinders within the LOX area that were not properly secured by evidence of only a single chain near the center of the cylinder that would allow the bottoms of the cylinders to kick out and strike other cylinders or constructed enclosures during a seismic event.
2. On 1/28/2016, at 10:22 a.m., there were (2) M-Sized compressed gas cylinders within the O2 Room that were not properly secured by evidence of only a single chain near the top of the cylinder that would allow the bottoms of the cylinders to kick out and strike other cylinders or walls within in the room during a seismic event.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1 S&C 13-25 LSC, S&C 15-27 LSC. This resulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to:
1. On 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., the humidity policy presented to the surveyor by the facility showed that the adopted humidity range for anesthetizing locations was 20% - 60%. Facility could not provide any documentation or IFU's (instruction's for use) for equipment within these areas to show that the equipment could tolerate the lower range of the adopted humidity level.
2. On 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., facility provide humidity levels documentation and the humidity was measured below 20% on the following dates: 12/10/13, 12/11/13 with no noted notification to Engineering as outlined within the Humidity Policy.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on record review and interviews it was determined through on-going dialog with the Maintenance Director and Maintenance 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 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., monthly maintenance was being performed by staff and there was no documentation showing that all staff had technician competence in maintaining the generator to the adopted 1999 edition of NFPA 110 standards.
2. On 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., there was no documentation provided to the surveyor showing monthly specific gravity checks on the batteries for the emergency power generator.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff 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 1/26/2016, during record review between 1:30 p.m. and 5:30 p.m., there was no documentation provided to the surveyor showing the required annual 90 minute test on the battery powered emergency lights for the generator and generator transfer switch room.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director and Maintenance Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to patients & staff (NFPA 70, 9.1.2, NEC 110-3.8). Findings include, but are not limited to:
1. On 1/27/2016, at 3:48 p.m., there was an open electrical junction box above the double doors leading into the Surgery Area.
2. On 1/27/2016, at 4:25 p.m., there was an open electrical junction box above the double doors adjacent to Rm. 105 and Rm. 106.
3. On 1/27/2016, at 4:57 p.m., there was a missing screw on the A/C vent grate within the Men's restroom adjacent to Imaging that allowed the vent grate to sag from the ceiling.
4. On 1/28/2016, at 9:23 a.m., there was a fluorescent light fixture that had broken prongs and missing bulbs within a room adjacent to the Staff Entrance on the east side of the building.
5. On 1/28/2016, at 9:33 a.m., there was a non UL60601-1 listed relocatable power tap in use within the MRI CT Room adjacent to the computers.
6. On 1/28/2016, at 9:40 a.m., there was a live transformer above the ceiling tiles within the CT Room that had wires that were not protected properly.
7. On 1/28/2016, at 10:28 a.m., there was a relocatable power tap on the floor within the Doctor's Sleep Room and Care Managers Office adjacent to the computers.
8. On 1/28/2016, at 10:32 a.m., there was a relocatable power tap on the floor behind the desk within the Epic-IS Room.
9. On 1/28/2016, at 10:35 a.m., there was a relocatable power tap on the floor within the HIM Room.
10. On 1/28/2016, at 11:22 a.m., there was a non UL60601-1 listed relocatable power tap in use within Patient Rehab adjacent to a fitness machine and exterior exit on the south side of the room.
11. On 1/28/2016, at 11:26 a.m., there was a relocatable power tap on the floor within the Computer Training Room.
12. On 1/28/2016, at 11:28 a.m., there was a non UL60601-1 listed relocatable power tap within the Infusion Wound Care Rm. #6 adjacent to the computer.
Surveyor was accompanied by the Maintenance Director and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to patients & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:
1. On 1/28/2016, during the facility tour between 2:00 p.m. and 2:30 p.m., there were non listed UL60601-1 relocatable power taps within the following patient care areas but not limited to the lab draw area (on counter for computer), Exam Rm. #1, Exam Rm. #2, Exam Rm. #3, Exam Rm. #4 and Exam Rm. #5.