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Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to separate sections of health care facilities. This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 19.1.2.3, 19.1.1.4, 19.1.2.3). Findings include, but are not limited to:
1. On 4/1/2013 during record review between 4:00 p.m. and 6:00 p.m., the life safety drawings did not match actual buildings or as built construction documents. Life safety drawings did not indicate suite boundaries, square footage, travel distances, smoke compartment sizes and boundaries.
2. On 4/3/2013 at 9:56 a.m., there was approximately 12" of unfinished/incomplete construction (fire caulking) on the existing 4-hr wall above the suspended ceiling in the corridor adjacent to the Main Entrance and Imaging Department.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary 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 4/2/2013 at 5:59 p.m., there was a large portion of the ceiling missing within an electrical closet in the ICU Unit.
2. On 4/2/2013 at 6:20 p.m., there were three unsealed ceiling penetrations that measured approximately 3" in diameter within the electrical closed, door #1290.
3. On 4/2/2013 at 6:21 p.m., there were missing ceiling tiles in the ceiling grid within the IT Closet near electrical closet #1290.
4. On 4/3/2013 at 10:25 a.m., there were three unsealed ceiling penetrations that measured approximately 3" in diameter within the boiler room.
5. On 4/3/2013 at 10:26 a.m., there were two unsealed ceiling penetrations that measured approximately 2.5" in diameter within an electrical room adjacent to the boiler room.
6. On 4/3/2013 at 10:50 a.m., there was an unsealed ceiling penetration that measured approximately 1" in diameter within the HIM File Room.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to maintain exit corridor doors to resist the passage of smoke into the means of egress in the event of a hostile fire event ( 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 4/2/2013 at 5:19 p.m., the doors leading to the solarium on floor three did not latch or close properly. SEE NOTE*
2. On 4/2/2013 at 5:51 p.m., the door for Patient Rm. 219 in Med. Surg., had a gap greater than ½ " when closed.
3. On 4/2/2013 at 5:52 p.m., the door leading to the locker room that was adjacent to Rm. 220 was not latching.
4. On 4/2/2013 at 6:18 p.m., there was one leaf of the double doors that separated the Surgi-Center from the corridor that were not closing or latching properly due to airflow within the building.
5. On 4/2/2013 at 6:20 p.m., there were door pins that were coming out of the hinges of the door #1290 that were for an electrical closet.
6. On 4/2/2013 at 6:27 p.m., the cross-corridor doors #1208 adjacent to a restroom were not closing and latching properly.
7. On 4/3/2013 at 9:10 a.m., there were missing ceiling tiles within the Communications Closet adjacent to Nuclear Medicine.
8. On 4/3/2013 at 10:27 a.m., the doors for the laundry room that opened to the corridor were not closing or latching properly due to airflow within the building.
9. On 4/3/2013 at 10:31 a.m., there were doors leading to the kitchen from the corridor that did not close properly due to the synchronizer missing or not working correctly.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.
*NOTE: This a repeat deficiency from the survey dated May 20, 2010.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to install proper hold-open devices that will release on the actuation of the fire alarm or fire sprinkler system. This resulted in the potential for smoke and fire to spread to other areas of the facility (LSC 19.2.2.3). Findings include, but are not limited to:
1. On 4/2/2013 at 6:19 p.m., there was a kick-down door prop attached to the door of the light bulb closet.
2. On 4/2/2013 between 5:16 p.m. and 5:50 p.m., there were plastic and wood door props located in the Supervisors Office of C-Section and Room 216.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to install vertical exit components that are constructed in accordance with approved standards. This resulted in the potential for the spread of fire/smoke vertically in multi-story facilities with a 1 hour rating. (LSC 8.2.5.2, 19.3.1.1). Findings include, but are not limited to:
1. On 4/3/2013 at 10:58 a.m., there was electrical conduit at the first floor within the west exit stairwell that was not servicing items within the stairwell.
Surveyor was accompanied the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledge the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to maintain accessible exits as required by 2000 NFPA 101, 19/18.2.2.2.4. Per exception 1 of this code reference, this condition is only allowed when the clinical needs of the patients require specialized security measures for their safety. This resulted in the potential for panic and injury to occupants. Findings include, but are not limited to:
1. On 4/3/2013 at 11:17 a.m., there were thumb locks on the main egress doors of the facility.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to provide adequate exit illumination to the public way with bulbs arranged so that if one bulb burned out there would still be adequate exit lighting. This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions (LSC 19.2.8). Findings include, but are not limited to:
1. On 4/2/2013 at 6:01 p.m., there was a single bulb fixture at the door that lead outside at the east stairwell from the first floor.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary 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 4/1/2013 during record review between 4:00 p.m. and 6:00 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 4/2/2013 between 5:22 p.m. and 5:25 p.m., there were emergency lights within OR #1 and OR #2 that were plugged directly into a wall outlet with flexible cords and were not hard wired.
3. On 4/2/2013 between 5:26 p.m. and 6:54 p.m., there were no emergency lights within OR #3 and Urology OR and Procedure Room across from Rm. A-2.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary 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 Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to maintain emergency preparedness plan current & readily available to all staff. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1). Findings include, but are not limited to:
1. On 4/3/2013 at 3:00 p.m., the disaster plan provided by the facility to the surveyor had an annual review date of 2009, and was past due for annual review since 2010. The plan did not have a Defend in Place Policy and the facility did not have documentation of an annual Hazard Vulnerability Assessment, no current transfer agreement's (dated 2007) and no transportation agreements. Disaster plans that were located at Nurse's stations were also dated 2009.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary 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 Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to provide fire drills and training for all staff. 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 4/2/2013 during record review between 4:00 p.m. and 6:00 p.m., facility documentation presented to the surveyors showed that there were missing fire drills for 1st quarter swing shift and 4th quarter swing shift in 2012. Documentation mentioned that the record for 1st quarter swing shift was lost. Staff indicated that if Facility Manager on duty at the time of a scheduled fire drill chooses not to have a fire drill, the fire drill is canceled. Fire drill forms that were filled out were incomplete, missing information such as type of fire, location of fire, number of patients relocated and time to complete simulated evacuation. Fire drill form for Day shift 1st quarter on 1/11/13 indicated that Lab could not hear the fire announcement over the alarm, HIM didn't know what to do with a person that is at the customer window and IT didn't hear a page and didn't know there was a fire drill. Staff indicated that horn strobes are installed throughout the facility, making code red pages intelligible and delayed staff response. On 4/3/2013 between 9:15 a.m. and 9:56 a.m., Surveyor's conducted three fire drills in different locations of the facility. The following is a summary of the three drills:
Drill #1 @ 9:15 on Floor 3 Family Birthing Center: Tech. Service Staff announced to three staff members standing at the Main Nurse Station, "you smell smoke, come with me". Staff Nurse #1 replied "take her". Staff Nurse #2 and Tech. Service Staff went into patient Rm. 302. Staff Nurse #2 was instructed and coached throughout the drill, no placement of simulated fire, no code red announcement by staff within the unit, staff complacent and no leadership, patient room doors were closed but were not checked, patient room doors were not marked, corridors were not cleared (chairs, beds, carts in C-section corridor, housekeeping cart left in the corridor near Rm. 306), two housekeeping staff members hid in a housekeeping room across from Rm. 306 during the drill, could not hear overhead page (not audible by RM. 309), two maintenance staff members went to a different location because they did not hear wear the fire was, pull station was not pulled until coached and Staff Nurse #2 asked, "you really want me to pull it", fire alarm was silenced prior to an overhead clear page, fire extinguisher on floor #3 was not initially used during drill, extinguishers were brought to floor #3 from the basement, fire extinguishers on floor #3 were obstructed by tables and chairs, Staff Nurse #1 and #3 did not participate in the drill and Disaster Plan at nurse's station was dated 2009.
Drill #2 @ 9:40 a.m. on Floor 2 Med. Surg.: drill was initiated within Patient Rm. 202, staff were coached to pull the fire pull station, fire room was not announced, there was no placement of a simulated fire, overhead code red page was paged "3rd floor" instead of 2nd floor, RN #1 said, "I would call code red", four staff members ignored the fire drill and continued to sit and work at the nurse's station, the Facilities Secretary told staff that a fire drills was being conducted and staff said replied "we know" and continued working, maintenance staff responded to the 2nd floor for the drill and one maintenance staff mentioned that he went to the 3rd floor because of what he heard on the overhead page, patient rooms doors were closed but not marked, staff did not check rooms for occupants, staff went back to work before an overhead "all-clear" announcement, corridors were not cleared (housekeeping cart by Rm. 203, X-ray machine charging in hall @ ICU entrance near a shower room), staff were complacent, fire alarm was silenced quickly after alarm was initiated, RN #1 stated were last fire drill was 6-months ago. Two nurse's in adjacent smoke compartment continued to work and did not prepare unit for possible incoming patients, corridors were not cleared, RN #2 in adjacent unit remained on the phone while the alarm was sounding, stated "what are they doing?", "this is the second drill this morning, patients need to sleep" and Disaster Plan at nurse's station was dated 2009.
Drill #3 @ 9:47 a.m. on Floor 1 Emergency Dept.: staff were told that they were going to do a drill, ER Tech #1 was coached to pull fire pull station, ER Tech #1 said, "I don't really need to do that, do I?", fire extinguisher within Emergency Department not used and blocked by a cart, no placement of simulated fire, no code red announcement by staff within the unit, staff complacent and no leadership, there was an overhead page but couldn't understand, speaker within unit was turned completely down, only checked on patient room, other patient rooms doors were closed, did not mark any patient room doors, corridors within suite were not cleared (med. carts, beds, housekeeping carts left in suite corridors), other staff within the ED were complacent during drill and did not react to alarm, ER Tech #1 said that she "would remove patients and take them outside", multiple maintenance staff responded to alarm with one fire extinguisher brought from another area of the hospital, alarm silenced right after fire alarm was initiated, ER Tech #1 commented that, "in a real fire it would not be just one person to do it all", ER Tech #1 stated last drill was several months ago.
Facilities Director and Biomedical Technician III stated they were in agreement with Surveyors that fire drill response by staff did not meet requirements and need to train the trainer and along with staff needing to be more active and not just explain what would be done.
2. On 4/2/2013 between 9:44 a.m. and 10:25 a.m., there were overhead pages from the PBX that indicated wrong floor and no room location of the simulated fires. During the simulated fires, Biomedical Technician III mentioned that there was a new person at the PBX and that they need to work with the PBX Operator to understand how to call the overhead pages and how to read the location message at the PBX. Biomedical Technician III acknowledged that the PBX Operator didn't correctly indicate the location of the simulated fire.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to install fire alarm system in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 18.3.4, 9.6). Findings include, but are not limited to:
1. On 4/3/2013 at 11:10 a.m., the main fire alarm panel at the entrance to the facility did not have a smoke detector located within 5' of the main panel.
2. On 4/3/2013 at 11:16 a.m., there was a fire alarm notification device within the patient restroom across from Exam #3 which are prohibited in patient treatment areas per NFPA 72 for private mode systems.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to install fire alarm system in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 19.3.4, 9.6). Findings include, but are not limited to:
1. During the walk through on 4/2/2013 at 4:45 p.m. through 4/3/2013 at 11:06 a.m., there were multiple fire alarm pull stations within the facility that were not installed according to NFPA 72 height requirements, locations include but not limited to 3rd floor adjacent to Rm. 304, OR Nurse's station, main lobby, adjacent to CT Control room, within boiler room, and mechanical room.
2. On 4/2/2013 at 9:02 a.m., there was a missing required smoke detector above the main fire alarm panel within the Technical Services area. The fire alarm panel was replaced in 2012 by Johnson Controls, plans, review and approval of the new fire alarm panel was not completed due to fire alarm plans not being submitted to Facilities Planning and Safety and Oregon State Fire Marshal's Office. The facility was informed by the City of LaGrande that they were not required to submit plans or gain approval from OSFM and FP&S because the replacement of the panel was a "like for like" replacement.
3. On 4/2/2013 at 9:08 a.m., 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. The label at the main alarm panel within Technical Services did not indicate the correct location of the fire alarm breaker.
4. On 4/2/2013 at 5:11 p.m., there was a fire alarm notification device within the Nursery on Floor #3 which are prohibited in patient treatment areas per NFPA 72 for private mode systems.
5. On 4/2/2013 between 5:18 p.m. and 6:00 p.m., there were missing fire alarm notification devices within staff areas, locations include but not limited to the C-Section sleep room, staff lounge on 2nd floor and Hospitalist Office sleep room.
6. On 4/3/2013 between 8:31 a.m. and 11:00 a.m., there were multiple fire alarm notification devices within patient treatment areas which are prohibited per NFPA 72 for private mode systems. Locations include but not limited to pool therapy room next to Rm. 14, occupational therapy rehab room, patient restrooms in patient rehab gym, patient restroom near blood draw #2, triage room #1, patient restroom in ED, which are prohibited in patient treatment areas per NFPA 72 for private mode systems.
7. On 4/3/2013 at 9:23 a.m., there was a missing smoke detection device within the skylight at the main lobby of the facility.
8. On 4/3/2013 at 9:40 a.m., there was a strobe in the physician sleep room that was not a chime/strobe.
9. On 4/3/2013 at 10:45 a.m., there was a missing smoke detection device within a mechanical room outside the kitchen.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary 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 4/1/2013 during record review between 4:00 p.m. and 6:00 p.m., there was no documentation for weekly, monthly, quarterly or annual testing for the fire alarm system. There was no documentation for staff technician competence. According to Biomedical Technician III, staff do weekly, monthly and quarterly testing of the fire alarm system. An annual fire alarm test was completed in January 2013 but only included initiating devices. The Facilities Director has login access to NFPA standards.
2. On 4/2/2013 at 5:31 p.m., there was a pull station blocked by a printer cabinet adjacent to the OR Nurse's station.
3. On 4/3/2013 at 10:37 a.m., there was a fire alarm pull station for the kitchen hood system blocked by a food cart within the facility kitchen.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13. This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 19.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. On 4/2/2013 between 8:30 a.m. and 8:58 a.m., there were missing Fire Sprinkler Riser Room signs on the doors of the Boiler Room and mechanical room within the kitchen.
2. On 4/2/2013 between 8:54 a.m. and 9:00 a.m., there was not a spare stock of sprinklers, two of each type, or a sprinkler wrench located in a spare sprinkler cabinet adjacent to the main fire sprinkler riser.
3. On 4/2/2013 at 8:58 a.m., there was an electrical switch for the air compressor controlling the dry pipe sprinkler system that was not secured.
4. On 4/2/2013 at 9:02 a.m., there was a missing Fire Department Connection (FDC) sign with a minimum of 6" red or white letters on a contrasting background placed above the FDC and a parking stall in front of the FDC was not marked as a fire lane.
5. On 4/2/2013 at 6:51 p.m., there was missing fire sprinkler protection within a restroom adjacent to the Surgical Waiting Rm. 198.
6. On 4/3/2013 between 9:21 a.m. and 10:47 a.m., there were missing or inadequate fire sprinkler protection within an alcove in the ceiling of the main entrance adjacent to the main entry/exit doors, within a skylight at the main entrance of the facility and within a skylight in the stairwell adjacent to the kitchen.
7. On 4/3/2013 at 9:44 a.m., there was a sprinkler head that was blocked by air handlers within the room housing Generator #3 adjacent to the ED ambulance entrance.
8. On 4/3/2013 between 10:46 a.m. and 10:53 a.m., there was missing or inadequate sprinkler coverage under air handlers exceeding 4' in Mechanical Rooms adjacent to the kitchen and in the Mechanical Room #3.
9. On 4/3/2013 at 11:20 a.m., there was an unsprinklered area under the Surgi Center that had combustibles stored in the area such as three 90 gallon recycle containers.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to ensure the sprinkler system is continuously maintained & in reliable operating condition. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:
1. On 4/1/2013 during record review between 4:00 p.m. and 6:00 p.m., there was no documentation for weekly, monthly, quarterly or annual testing for sprinklers. There was no documentation for an annual forward flow test, no record of the 5 year test and there was no documentation for staff technician competence. According to Biomedical Technician III, staff do weekly, monthly and annual testing of the fire sprinkler system. The Facilities Director has login access to NFPA standards and mentioned that the facility is only 90% covered with a fire sprinkler system.
2. During the facility tour on 4/2/2013 between 4:45 p.m. and 7:00 p.m., the following deficiencies were noted with sprinkler heads: gauges on wet sprinkler riser were dated 1982 and there was no date on gauges for the dry sprinkler riser, gauges past due for replacement or recalibration since 1987; painted heads in Echo Room, ED Room and missing escutcheon plates in respiratory storage.
3. During the facility tour on 4/3/2013 between 8:30 a.m. and 11:06 a.m., the following deficiencies were noted with sprinkler heads: dropped sprinkler head in communications closet within lab draw; three loose escutcheon plates in outside overhang near main lobby entrance; missing escutcheon plate for sprinkler in ambulance overhang near ED; a sprinkler head that was siliconed to a ceiling tile and approximately 2' from another sprinkler head within the corridor adjacent to the boiler room; painted head within laundry room; obstructed head within freezer by light; painted head within sewing room; painted head within CPS bathroom and painted heads within main lobby at main entrance.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to conduct the annual forward flow testing of the sprinkler system. 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 4/1/2013 during record review between 4:00 p.m. and 6:00 p.m., there was no documentation for the required annual forward flow test of the sprinkler system, last test was conducted in March of 2011 and showed a pitot reading of 7 pounds per square inch (PSI) and a calculated gallons per minute (GPM) of 1263 for the system, system requirements noted on the sprinkler riser showed 2125 GPM @ 67 PSI.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to maintain fire extinguishers in accordance with adopted standards. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:
1. On 4/1/2013 during record review between 4:00 p.m. and 6:00 p.m., there was no documentation of staff technician competence. According to Biomedical Technician III, staff do monthly and annual testing of the fire extinguishers. The Facilities Director has login access to NFPA standards. During an interview with the maintenance staff member responsible for monthly checks on fire extinguishers, they mentioned that they "sometimes flip the extinguisher" during their checks. They also mentioned that the use the NFPA 10 standard. The fire extinguisher checklist that was shown to the surveyor listed only to check the gauge, check seal and turn it up side down. Surveyor was also presented with a NFPA 10 standard that was not the adopted standard.
2. On 4/2/2013 during the facility tour between 4:45 p.m. and 7:00 p.m., the following fire extinguisher deficiencies were observed: obstructed fire extinguisher with chair and table near Rm. 305; multiple fire extinguishers missing monthly checks from 2007 or 2008-2010 (noted but not limited to B22, B27, B38, B39, B43, B54; and fire extinguisher mounted to high at ICU Nurse Station.
3. On 4/3/2013 during the facility tour between 8:30 a.m. and 11:06 a.m., the following fire extinguisher deficiencies were observed: a discharged fire extinguisher hanging on the wall in the Lab Draw (B15); the K-Class fire extinguisher within the kitchen was mounted too high; obstructed fire extinguisher in Mechanical Rm. 3; fire extinguisher in Linen Storage mounted too high; fire extinguisher in MRI mounted too high; and multiple fire extinguishers missing monthly checks from 2007 or 2008-2010.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to maintain fire extinguishers in accordance with adopted standards. This resulted in the potential for fires to progress beyond incipient stage (LSC 19/18.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:
1. On 4/3/2013 at 11:14 a.m., there was a fire extinguisher at the nurse's charting station that was not properly sized (1A 10B:C).
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to install 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, 19.3.2.6, NFPA 96 A.1.1.4, UL300). Findings include, but are not limited to:
1. On 4/3/2013 at 10:35 a.m., there was a griddle and panini machine that was not protected under the kitchen hood at the servery.
2. On 4/3/2013 at 10:38 a.m., the kitchen hood was extremely greasy and dirty above the fryer. Documentation presented to the surveyor shows that the hood was last cleaned on 1/13/2013 by General Fire.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of the following conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary 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 4/3/2013 between 8:30 a.m. and 11:06 a.m., there were unlisted portable space heaters found within the HIM Office and the Administration Office. Biomedical Technician III stated that there were multiple portable space heaters of the same type throughout the facility.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" from 40" up to 80" above the floor and no projections exceeding 4 1/2" below 40" from the floor. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10, S&C). Findings include, but are not limited to:
1. On 4/2/2013 at 5:00 p.m., there was a C.O.W. (computer on wheels) that was plugged into a wall outlet within the corridor outside of Rm. 304.
2. On 4/2/2013 at 5:18 p.m., there were beds, carts and bins within the corridor adjacent to the C-Section OR.
3. On 4/2/2013 at 5:46 p.m., there were charting stations mounted to the corridor walls on the 2nd floor that were not self-closing.
4. On 4/2/2013 between 6:04 p.m. and 6:31 p.m., there were phones that projected 5" into the corridor located near Rm. 211 and adjacent to the Compliance Coordinators Office.
5. On 4/3/2013 at 9:41 a.m., there was a cart in the exit access corridor outside of the Emergency Department.
6. On 4/3/2013 at 10:33 a.m., there were soiled linen carts in the corridor outside of the laundry room.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to ensure that no furnishings or decorations of highly flammable character are used, unless in limited quantities or flame retardant. This resulted in the potential for excessive fire spread (LSC 19.7.5.4). Findings include, but are not limited to:
1. On 4/2/2013 during the facility tour between 4:45 p.m. and 7:00 p.m., the following areas were found to have foam based plants: East Elevator Lobby 3rd floor, Visitor Elevator Lobby 3rd floor, adjacent to Rm. 305 and Visitor Elevator Lobby 2nd floor.
2. On 4/3/2013 during the facility tour between 8:00 a.m. and 11:00 a.m., the following areas were found to have foam based plants: Lobby near the Laboratory, Lobby alcove at Main Entrance, adjacent to Gift Shop and main waiting area.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to ensure that no storage of highly flammable character existed in the corridors. This resulted in the potential for excessive fire spread (LSC 19.7.5.5, Exhibit 19.23). Findings include, but are not limited to:
1. On 4/3/2013 at 10:33 a.m., there was more then 32-gallons of soiled linen within carts stored outside the laundry within the corridor.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to provide safe storage for compressed gas. This resulted in the potential for injury to staff and residents from a damaged compressed gas cylinder releasing unexpectedly. (LSC 19.3.2.4, 4.3.1.1.2). Findings include, but are not limited to:
1. On 4/2/2013 at 6:25 p.m., there was an unsecured compressed gas cylinder, only one chain, within the Pulmonary Room.
2. On 4/3/2013 at 8:55 a.m., there were unsecured compressed gas cylinders, only one chain, within the Microbiology Lab and Mechanical Room adjacent to the kitchen.
Based on observations, record review and interviews it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary 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, 4.3.1.1.2). Findings include, but are not limited to:
3. On 4/2/2013 between 6:02 p.m. and 6:29 p.m., there were electrical outlets/switches within 60" of the finish floor within the Oxygen storage Rm. 2066 and Rm. 1252.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary 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 4/2/2013 at 4:00 p.m., there was no documentation provided to the surveyor showing an annual med gas certification and no outlet testing reports.
2. On 4/2/2013 at 6:01 p.m., there was a Med Gas shutoff cabinet that was obstructed by papers adjacent to the Nurse Managers Office.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1. This resulted in the potential for injury to patients during medical procedures. Findings include:
1. On 4/1/2013 during record review between 4:00 p.m. and 6:00 p.m., the Surgery Director stated that the facility does not have a humidity policy because they can not stay within the ASHRAE 170 standard (30%-60%). They also stated that they understand it is a high-risk but they will not cancel any surgeries. They mentioned that they can only comply with the 30%-60% for a couple of days throughout the year, generally in August. The Surgery Director indicated that they plan to build new ORs in 5-years and will not fix until that time. Humidity levels were measured under 30% on the following days in the previous three months that the surveyor reviewed: OR1 1/1-1/24, 1/26 p.m. reading, 1/27-1/29 a.m. reading, 2/1-2/12, 2/13 p.m. reading - 2/28, 3/3 p.m. reading - 3/10, 3/16-3/20 a.m. reading, 3/21-3/27 a.m. reading and 3/31; OR2 1/1-1/25 p.m. reading, 1/27-1/29 a.m. reading, 2/1-2/28, 3/4-3/6 a.m. reading, 3/7-3/10 p.m. reading, 3/17-3/20 a.m. reading, 3/21-3/27 p.m. reading and 3/31; OR3 1/1-1/8, 1/10-1/29 a.m. reading, 2/2-2/21, 2/23-2/28, 3/3 p.m. reading - 3/10, 3/16 p.m. reading - 3/20 a.m. reading and 3/21-3/27 a.m. reading; OR4 1/1-1/25 a.m. reading 1/26 p.m. reading - 1/29, 2/2-2/28, 3/4-3/10, 3/16 p.m. reading - 3/20 a.m. reading and 3/21-3/27 a.m. reading; and C-Section 1/1-1/25 p.m. reading, 1/26 p.m. reading - 1/29 a.m. reading, 2/2-2/28, 3/3 p.m. reading - 3/6 a.m. reading, 3/7-3/10, 3/16 p.m. reading - 3/20 a.m. reading and 3/21-3/27 a.m. reading.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to maintain dryers complying with NFPA 54. This resulted in the potential for unexpected ignition source & excessive fire spread. Findings include, but are not limited to:
1. On 4/3/2013 at 10:38 a.m., there was excessive lint buildup at the top of the dryers and gas piping to the dryers within the laundry room of the facility.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.


Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to provide task illumination at the generator and transfer switches. This resulted in the potential for panic and confusion for staff and residents in a power outage. Findings include, but are not limited to:
2. On 4/1/2013 during record review between 4:00 p.m. and 6:00 p.m, the Biomedical Technician III indicated taht there was no emergency task illumination at any of the three generator sets or trasnfer switch locations.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and record review during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility to provide fire drills and in-service training. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing patients to smoke and fire in the facility (LSC 19.7.1.2, A. 19.7.1.2). Findings include, but are not limited to:
1. On 4/2/2013 between 9:44 a.m. and 10:25 a.m., there were overhead pages from the PBX that indicated wrong floor and no room location of the simulated fires. During the simulated fires, Biomedical Technician III mentioned that there was a new person at the PBX and that they need to work with the PBX Operator to understand how to call the overhead pages and how to read the location message at the PBX. Biomedical Technician III acknowledged that the PBX Operator didn't correctly indicate the location of the simulated fire.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions

Based on observations, record review and interviews it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary that the facility failed to properly maintain the generators. 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 4/2/2013 during record review between 4:00 p.m. and 6:00 p.m., there was no documentation provided to the surveyors for monthly checks or weekly water level check/monthly specific gravity level checks for any of the three generators. There was no documentation of a 3yr/4hr load test for any of the three generators. There was no annual documentation for Generator #1 or Generator #2. The Biomedical Technician II informed surveyors that Facilities Staff were conducting the weekly and monthly testing of the generators and the facility had no documentation showing technician competence and the Facilities Director had the login for NFPA Manuals.
2. On 4/2/2013 between 7:15 a.m. and 7:23 a.m., emergency shut off switches for the three generators were located inside of the generator enclosures.
3. On 4/2/2013 at 7:18 a.m., there were sealed batteries preventing maintenance for Generator Set #1.
4. On 4/2/2013 at 7:24 a.m., there was a exhaust leak within the generator room for Generator Set #3.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary 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 residents & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:
1. On 4/2/2013 during the facility tour between 4:45 p.m. and 7:00 p.m., the following electrical deficiencies were found: power strips daisy chained together in the Radio Room on the roof, nurse's station in ICU and nurse's station floor 2; Non-patient power strips at the nurse's station floor 3, OR nurse's station, ICU, nurse's station floor 2, clean utility room across from Rm. 211, Surgi-Center waiting room, across from Rm. A11, on Pyxis machine across from Rm. 202 & 214, Wound care, Echo Room, Exam Rm. 2 and Ambulatory EEG; Power strips on the floor in the Ambulatory EEG room, Medical Coordinators Office, Credentials Coordinators Office, Hospitalist Office, Clean Utility Room across from Rm. 211, Surgi-Center waiting room and Staff room near nursery; Household microwaves at nurse's station in ICU, Nourishment Station 2nd floor and 3rd floor, Staff Lounge of Med. Surge and kitchenette across from Surgi-Center; permanently attached power strip in Pulmonary; Appliances plugged into power strips in nourishment area by EEG and staff lounge of Respiratory Care; and Broken/Damaged power strip across from A-11.
2. On 4/2/2013 at 6:43 p.m., there was a loose electrical box on the wall of the staff lounge in Respiratory Care.
3. On 4/2/2013 at 6:50 p.m., there was a broken face plate on an electrical outlet in Rm. A-12.
4. On 4/3/2013 during the facility tour between 8:30 a.m., and 11:06 a.m., the following electrical deficiencies were found: Power strips daisy chained together in Mail room, Non-patient power strips in Recovery Room 1st floor, Managers Office next to Rm. 1, Nurse's station 1st floor, Blood draw #2 of Lab, Lab Draw closet, Treatment/Trauma Rooms of the ED for computers, ED nurse's station, CT Scan Room; Power strips on the floor in Recovery Room 1st floor, Managers Office next to Rm. 1, Pharmacy, HIM Area, Managers Office in HIM Area, Mail Room, Foundation Managers Office, Nuclear Medicine Office, Surgery Managers Office, Gift Shop, Charting Station in ED, Basement Server Room, Dietary Office, Materials Room, MRI, Systems Tech. Office, Technical Services and Sterilization; Household microwaves in room next to Staff Room door to lab, above sink in ED Admitting, Cafeteria, Staff Lounge in basement and Main Facility Kitchen; Permanently attached power strips in Mail Room, surveillance outside of Communications Center and Tech. Services at computers; Appliances plugged into power strips at Nurse's station 1st floor, HIM area, Administration, Surgery Managers Office, ED Nurse's station and Main Facility Kitchen; and Broken/Damaged power strip in Mail Room.
5. On 4/3/2013 between 9:10 a.m. and 10:50 a.m. and , there was a electrical junction box that was missing a cover in the Nuclear Medicine, Blowdown Room and Phone Room near Mechanical Room 3.
6. On 4/3/2013 between 9:15 a.m. and 10:55 a.m., there were extension cords in use with lamps, printers and power strips plugged into the extension cords in the Main Lobby adjacent to Radiology and Emergency Department, Materials Room and Work Cubby Space.
7. On 4/3/2013 at 11:00 a.m., there was a 6:2 cube adapter in the Communications Center.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Director, Biomedical Technician III and Facilities Secretary 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 residents & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:
1. On 4/3/2013 between 11:12 a.m. and 11:15 a.m., there were non-patient power strips in the audio booth, in patient exam rooms 1-4 and at the nurse's charting station.
Surveyor was accompanied by the Facilities Director, Biomedical Technician III and Facilities Secretary who acknowledged the existence of these conditions.