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Based on records review and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator that the facility failed to maintain a set of Life Safety drawings for the facility to ensure construction is maintained as originally built and approved. 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 6/25/13, during document review between 1:00 p.m. and 6:00 p.m., the facility did not provide any life safety drawings to the surveyors indicating smoke barrier walls, square footage, travel distances, hazardous rooms or smoke compartments.

Based on observations, records review, and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, at 9:30 a.m., the emergency exit from Med. Surge was dragging on the corridor floor and the door to Patient Rm.10 did not latch or close properly.

2. On 6/25/13, at 9:57 a.m., the door at the west end of the Cafeteria across from CT Scan did not latch or close properly and the door at Radiology across from the Emergency Department did not latch or close properly.

3. On 6/25/13, during document review, there was no documentation of an inspection and maintenance schedule to maintain doors.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator that the facility failed to provide a one hour separation between hazardous areas and the corridor. This resulted in the potential for residents & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 19.3.2). Findings include, but are not limited to:

1. On 6/26/13, at 9:03 a.m., there were patient rooms within in the OB Department and Nursery that were converted to temporary storage rooms and did not have automatic closers on the doors.

2. On 6/26/13, at 9:35 a.m., there was a storage room door that did not have an automatic closer on the door next to Patient Rm. 9.

3. On 6/26/13, at 11:50 a.m., there was a missing automatic door closure on the storage room within the Emergency Department.

Based on records review and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, during document review between 1:00 p.m. and 6:00 p.m., there was no documentation showing the required annual 90 minute test on emergency lights within the facility.

Based on interviews and records review during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, during document review between 1:00 p.m. and 6:00 p.m., the disaster plan provided by the facility to the surveyor had an annual review date of July 2011, and was past due for annual review since July 2012. The Disaster Plan did not have policies for specific emergencies the facility may encounter (Internal Flood, External Flood, Tsunami, Earthquake, Hazardous Materials Incident, etc.). The facility did not have a Hazard Vulnerability Analysis specific to the facility or an Emergency Utility Shutoff Map. There was no Defend-in-Place policy. The facility did not have transfer and transportation agreements with equivalent facilities. The Flip Chart that was provided to the surveyor also had a date of July 2011.

Based on observations, records review, and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator that the facility failed to provide fire drills 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 6/25/13, during document review between 1:00 p.m. and 6:00 p.m., facility documentation presented to the surveyors showed that there were missing fire drill documentation for 4th quarter day and night shift in 2012 and 1st quarter day and night shift in 2013. Documentation presented to the surveyor for fire drills had missing information such as type of fire, number of simulated patients evacuated from the affected smoke compartment, problems with the building and staff performance. Surveyors conducted two fire drills; first drill was conducted during day shift on 6/26/13 and staff did not clear hallways, no Code Red announcement, no overhead page announcement identifying the location of the fire and the fire alarm pull station was not activated; second drill was conducted during night shift on 6/26/13 and there was no announcement of a Code Red, no overhead page announcement identifying the location of the fire and the fire alarm pull station was not activated. SEE NOTE *.

NOTE *: This was a repeat deficiency from the October 2008 survey.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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. On 6/25/13, at 12:15 p.m., there was a missing required smoke detector above the main fire alarm control panel within the basement area. The fire alarm panel was replaced in July 2011 by the alarm company, 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 alarm company that with the panel in complete failure, there was not enough time to go through the process of months of plan submissions and approval processes.

2. On 6/25/13, at 1:25 p.m., there was a smoke detector base missing the smoke detector head within the Female Changing Room in Surgery. There was also no trouble alarm at the main Fire Alarm Control Panel for this missing device.

3. On 6/26/13, at 12:15 p.m., the electrical panel housing the breaker for the Fire Alarm Control Panel was not labeled in red (FACP) and did not have a mechanical set screw lock on the breaker.

4. On 6/26/13, at 12:15 p.m., there was not a sign on the exterior and interior doors leading to the Fire Alarm Control Panel (FACP). The location of the breaker for the FACP was not identified on the FACP.

Based on observations, records review, and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, during document review between 1:00 p.m. and 6:00 p.m., there was no documentation provided to the surveyors showing the required monthly and annual testing for the fire alarm system only quarterly inspections were conducted. There was no documentation for staff technician competence and staff did not have access to the adopted NFPA 72 standard, 1999 edition.

2. On 6/25/13, at 1:17 p.m., there was a fire alarm pull station within the semi-restricted area of surgery that was obstructed by equipment storage.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, at 1:21 p.m., there was missing fire sprinkler head within the Operating Room.

2. On 6/26/13, at 9:40 a.m., there was missing fire sprinkler head at exterior overhang adjacent to Information Technology at the south end of the building.

3. On 6/26/13, at 11:36 a.m., there was a fire sprinkler head within 4 inches of the exterior building wall of the exterior entrance/exit of Cardio Pulmonary entrance/exit.

4. On 6/26/13, at 4:10 p.m., there was not a sign on the exterior and interior doors leading to the Fire Sprinkler Riser room.

Based on observations, records review, and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, during document review between 1:00 p.m. and 6:00 p.m., there was no documentation provided to the surveyors showing the required weekly, monthly and quarterly testing on the fire sprinkler system. There was no documentation or record of the 5 year test and there was no documentation for staff technician competence and staff did not have access to the adopted NFPA 13 standard, 1999 edition.

2. During the facility tour on 6/26/13, between 8:42 a.m. and 2:00 p.m., the following deficiencies were noted with sprinkler heads: corroded sprinkler heads at Main Entry, Receiving adjacent to Kitchen, outside of Med. Surge Emergency exit on south side of facility, entrance/exit to Cardio-Pulmonary (red door) and bathroom of Doctor Sleep Room; painted sprinkler heads in Case Managers Office, closet of Rm. 14, Clean Storage Room, bathroom of Rm. 5, Scullery, Cardio-Pulmonary, entrance/exit to Cardio-Pulmonary (red door), Mammography Room, Housekeeping Room, Doctor Sleep Room, bathroom of Doctor Sleep Room, closet next to Anesthesia Office, outside of the Clean Room, Sterile Processing Room and Lab Director's Office; foreign material on sprinkler head in OB Shower Room; female connections on Fire Department Connection do not swivel and an obstructed sprinkler head within the Nursing Coordinators Office closet.

3. During the facility tour on 6/26/13, between 9:00 a.m. and 11:09 a.m., there were multiple hose cabinets throughout the facility that were still operational. According to the Facilities Manager, there is no training provided to staff to use these hose cabinets in the event of a fire and there are no records identifying testing of the system or hose within the cabinet.

4. On 6/26/13, at 12:04 p.m., sprinkler gauges are past due for replacement or recalibration since 2008.



5. On 6/25/13, during record review between 1:00 p.m. and 6:00 p.m., there was no documentation provided to the surveyors showing a current forward flow test for the sprinkler system.

Based on observations, records review, and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, during record review between 1:00 p.m. and 6:00 p.m., the facility staff did not have access to the NFPA 10 1998 edition standard. The facility did not have the previous 3-years of fire extinguisher tags.

2. On 6/26/13, at 10:52 a.m., there was a cabinet obstructing a fire extinguisher within the Micro Lab.

Based on observations, records review, and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator that the facility failed to ensure safe smoking practices by residents in the facility in accordance with facility policies and life safety regulations. This resulted in the potential for exposing residents to a fire and/or smoke environment (LSC 19.7.4). Findings include, but are not limited to:

1. On 6/26/13, between 8:42 a.m. and 9:43 a.m., there were smoking materials found in the landscaping and within an unapproved disposal container at the main entrance. The Smoking Policy for facility provided to the surveyors explains that the facility is a smoke free facility.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/26/13, at 8:19 a.m., the rooftop exhaust fan was not accessible for inspection or cleaning purposes. There was no hinge kit or flexible wiring on the rooftop exhaust fan.

2. On 6/26/13, at 9:50 a.m., there was a button on the wall of the Kitchen that was labeled as the suppression system for the Gaylord System on the kitchen fan which has been disconnected according to Kitchen Staff and the Facilities Manager.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator that the facility failed to ensure that exit egress remained clear & unobstructed. 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 6/26/13, at 10:45 a.m., there were food carts, a freezer and a BioMed freezer within the corridor adjacent to the Cafeteria and CT Scan Room.

2. On 6/26/13, at 10:58 a.m., there were housekeeping items, a chair, a desk, a X-Ray Machine, trash, an EKG Machine, an empty hospital bed and a C-Arm Machine within the corridor adjacent to the Emergency Department.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator that the facility failed to ensure that no curtains of highly flammable character were used. This resulted in the potential for excessive fire spread (LSC 19.7.5.1). Findings include, but are not limited to:

1. On 6/26/13, at 8:51 a.m., the privacy curtains installed at the Blood Draw Station that did not have a fire spread label attached.

Based on observations and interviews it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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:

1. On 6/26/13, at 9:20 a.m., there were O2 cylinders being stored within the clean storage room in Med. Surge that had electrical outlets within 60" of the finish floor.

2. On 6/26/13, at 11:30 a.m. there were O2 cylinders being stored within the Cardio Pulmonary Room that had electrical outlets within 60" of the finish floor.

Based on observations, records review, and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, during document review between 1:00 p.m. and 6:00 p.m., there was no documentation provided to the surveyor showing an annual Med Gas Certification and no outlet testing reports.

2. On 6/25/13, at 1:23 p.m., there was an obstructed Med Gas Cabinet for the OR within the Sterile Processing Room.

Based on observations, records review, and interviews it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator that the facility failed to properly maintain the generator. 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 6/25/13, during record review between 1:00 p.m. and 6:00 p.m., there was no documentation provided to the surveyor for weekly water checks or monthly specific gravity checks on the generator. There was no documentation of a 3 yr/4 hr. load bank test on the generator. The facility had no documentation showing technician competence and access to NFPA 110 1999 edition.

2. On 6/26/13, at 12:23 p.m., the emergency shutoff for the generator was located within the generator room.

3. On 6/26/13, at 12:25 p.m., the normal vent for the generator fuel tank did not terminate a minimum of 12' above finish grade.

4. On 6/26/13, at 12:23 p.m., there was no emergency battery powered lighting within the generator enclosure.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, at 1:21 p.m., three relocatable power taps were on the floor of the OR, two of which were non-patient.

2. On 6/26/13, during the facility tour between 8:00 a.m. and 4:00 p.m., the following electrical deficiencies were found: there were three open electrical junction boxes within the mechanical penthouse; there was a junction box with flexible wiring on the floor of the mechanical penthouse; there was an obstructed electrical panel within the Nursing Office, Laboratory and Laundry Room; there was an extension cord that went through an exterior wall on the south end of the building outside Med. Surge, unknown what it is powering; there were relocatable power taps on the floor within the Laboratory, Radiology Reading Room, Medical Records Room, Med. Staff Coordinators Room, Executive Assistant's Office; there was a refrigerator plugged into a relocatable power tap in the Laboratory; there was an extension cord powering the Analyzer Machine within the Laboratory; there was an overheating transformer in Medical Records Room for a dust buster; there were non-patient relocatable power taps on the floor in the Cardio Pulmonary Room powering the Cardio Monitor and exercise equipment and in the PFT Monitor Room; there was a refrigerator and household microwave within the Cardio Pulmonary Room that was for staff use; there was a relocatable power tap being permanently used for the mechanical laundry soap machine within the Laundry and there were painted breakers within the breaker panel in the basement for the fire alarm control panel.

Based on the observations and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator that the facility failed to install alcohol gel hand sanitizing dispensing stations away from sources of ignition. This resulted in the potential for injury to residents and staff (LSC 19.2.3.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623). Findings include, but are not limited to:

1. On 6/26/13, at 9:21 a.m., there was an alcohol based hand rub station (ABHR) installed above an electrical switch in the Dirty Utility Room in Med. Surge adjacent to Rm. 3.

2. On 6/26/13, at 9:27 a.m., there was an alcohol based hand rub station (ABHR) installed less than 1" to the side of the electrical switch in Rm. 10.

3. On 6/26/13, at 10:51 a.m., there was an alcohol based hand rub station (ABHR) installed above an electrical outlet in the Microbiology Room.

Based on records review and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator that the facility failed to maintain a set of Life Safety drawings for the facility to ensure construction is maintained as originally built and approved. 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 6/25/13, during document review between 1:00 p.m. and 6:00 p.m., the facility did not provide any life safety drawings to the surveyors indicating smoke barrier walls, square footage, travel distances, hazardous rooms or smoke compartments.

Based on observations, records review, and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, at 9:30 a.m., the emergency exit from Med. Surge was dragging on the corridor floor and the door to Patient Rm.10 did not latch or close properly.

2. On 6/25/13, at 9:57 a.m., the door at the west end of the Cafeteria across from CT Scan did not latch or close properly and the door at Radiology across from the Emergency Department did not latch or close properly.

3. On 6/25/13, during document review, there was no documentation of an inspection and maintenance schedule to maintain doors.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator that the facility failed to provide a one hour separation between hazardous areas and the corridor. This resulted in the potential for residents & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 19.3.2). Findings include, but are not limited to:

1. On 6/26/13, at 9:03 a.m., there were patient rooms within in the OB Department and Nursery that were converted to temporary storage rooms and did not have automatic closers on the doors.

2. On 6/26/13, at 9:35 a.m., there was a storage room door that did not have an automatic closer on the door next to Patient Rm. 9.

3. On 6/26/13, at 11:50 a.m., there was a missing automatic door closure on the storage room within the Emergency Department.

Based on records review and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, during document review between 1:00 p.m. and 6:00 p.m., there was no documentation showing the required annual 90 minute test on emergency lights within the facility.

Based on interviews and records review during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, during document review between 1:00 p.m. and 6:00 p.m., the disaster plan provided by the facility to the surveyor had an annual review date of July 2011, and was past due for annual review since July 2012. The Disaster Plan did not have policies for specific emergencies the facility may encounter (Internal Flood, External Flood, Tsunami, Earthquake, Hazardous Materials Incident, etc.). The facility did not have a Hazard Vulnerability Analysis specific to the facility or an Emergency Utility Shutoff Map. There was no Defend-in-Place policy. The facility did not have transfer and transportation agreements with equivalent facilities. The Flip Chart that was provided to the surveyor also had a date of July 2011.

Based on observations, records review, and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator that the facility failed to provide fire drills 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 6/25/13, during document review between 1:00 p.m. and 6:00 p.m., facility documentation presented to the surveyors showed that there were missing fire drill documentation for 4th quarter day and night shift in 2012 and 1st quarter day and night shift in 2013. Documentation presented to the surveyor for fire drills had missing information such as type of fire, number of simulated patients evacuated from the affected smoke compartment, problems with the building and staff performance. Surveyors conducted two fire drills; first drill was conducted during day shift on 6/26/13 and staff did not clear hallways, no Code Red announcement, no overhead page announcement identifying the location of the fire and the fire alarm pull station was not activated; second drill was conducted during night shift on 6/26/13 and there was no announcement of a Code Red, no overhead page announcement identifying the location of the fire and the fire alarm pull station was not activated. SEE NOTE *.

NOTE *: This was a repeat deficiency from the October 2008 survey.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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. On 6/25/13, at 12:15 p.m., there was a missing required smoke detector above the main fire alarm control panel within the basement area. The fire alarm panel was replaced in July 2011 by the alarm company, 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 alarm company that with the panel in complete failure, there was not enough time to go through the process of months of plan submissions and approval processes.

2. On 6/25/13, at 1:25 p.m., there was a smoke detector base missing the smoke detector head within the Female Changing Room in Surgery. There was also no trouble alarm at the main Fire Alarm Control Panel for this missing device.

3. On 6/26/13, at 12:15 p.m., the electrical panel housing the breaker for the Fire Alarm Control Panel was not labeled in red (FACP) and did not have a mechanical set screw lock on the breaker.

4. On 6/26/13, at 12:15 p.m., there was not a sign on the exterior and interior doors leading to the Fire Alarm Control Panel (FACP). The location of the breaker for the FACP was not identified on the FACP.

Based on observations, records review, and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, during document review between 1:00 p.m. and 6:00 p.m., there was no documentation provided to the surveyors showing the required monthly and annual testing for the fire alarm system only quarterly inspections were conducted. There was no documentation for staff technician competence and staff did not have access to the adopted NFPA 72 standard, 1999 edition.

2. On 6/25/13, at 1:17 p.m., there was a fire alarm pull station within the semi-restricted area of surgery that was obstructed by equipment storage.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, at 1:21 p.m., there was missing fire sprinkler head within the Operating Room.

2. On 6/26/13, at 9:40 a.m., there was missing fire sprinkler head at exterior overhang adjacent to Information Technology at the south end of the building.

3. On 6/26/13, at 11:36 a.m., there was a fire sprinkler head within 4 inches of the exterior building wall of the exterior entrance/exit of Cardio Pulmonary entrance/exit.

4. On 6/26/13, at 4:10 p.m., there was not a sign on the exterior and interior doors leading to the Fire Sprinkler Riser room.

Based on observations, records review, and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, during document review between 1:00 p.m. and 6:00 p.m., there was no documentation provided to the surveyors showing the required weekly, monthly and quarterly testing on the fire sprinkler system. There was no documentation or record of the 5 year test and there was no documentation for staff technician competence and staff did not have access to the adopted NFPA 13 standard, 1999 edition.

2. During the facility tour on 6/26/13, between 8:42 a.m. and 2:00 p.m., the following deficiencies were noted with sprinkler heads: corroded sprinkler heads at Main Entry, Receiving adjacent to Kitchen, outside of Med. Surge Emergency exit on south side of facility, entrance/exit to Cardio-Pulmonary (red door) and bathroom of Doctor Sleep Room; painted sprinkler heads in Case Managers Office, closet of Rm. 14, Clean Storage Room, bathroom of Rm. 5, Scullery, Cardio-Pulmonary, entrance/exit to Cardio-Pulmonary (red door), Mammography Room, Housekeeping Room, Doctor Sleep Room, bathroom of Doctor Sleep Room, closet next to Anesthesia Office, outside of the Clean Room, Sterile Processing Room and Lab Director's Office; foreign material on sprinkler head in OB Shower Room; female connections on Fire Department Connection do not swivel and an obstructed sprinkler head within the Nursing Coordinators Office closet.

3. During the facility tour on 6/26/13, between 9:00 a.m. and 11:09 a.m., there were multiple hose cabinets throughout the facility that were still operational. According to the Facilities Manager, there is no training provided to staff to use these hose cabinets in the event of a fire and there are no records identifying testing of the system or hose within the cabinet.

4. On 6/26/13, at 12:04 p.m., sprinkler gauges are past due for replacement or recalibration since 2008.



5. On 6/25/13, during record review between 1:00 p.m. and 6:00 p.m., there was no documentation provided to the surveyors showing a current forward flow test for the sprinkler system.

Based on observations, records review, and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, during record review between 1:00 p.m. and 6:00 p.m., the facility staff did not have access to the NFPA 10 1998 edition standard. The facility did not have the previous 3-years of fire extinguisher tags.

2. On 6/26/13, at 10:52 a.m., there was a cabinet obstructing a fire extinguisher within the Micro Lab.

Based on observations, records review, and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator that the facility failed to ensure safe smoking practices by residents in the facility in accordance with facility policies and life safety regulations. This resulted in the potential for exposing residents to a fire and/or smoke environment (LSC 19.7.4). Findings include, but are not limited to:

1. On 6/26/13, between 8:42 a.m. and 9:43 a.m., there were smoking materials found in the landscaping and within an unapproved disposal container at the main entrance. The Smoking Policy for facility provided to the surveyors explains that the facility is a smoke free facility.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/26/13, at 8:19 a.m., the rooftop exhaust fan was not accessible for inspection or cleaning purposes. There was no hinge kit or flexible wiring on the rooftop exhaust fan.

2. On 6/26/13, at 9:50 a.m., there was a button on the wall of the Kitchen that was labeled as the suppression system for the Gaylord System on the kitchen fan which has been disconnected according to Kitchen Staff and the Facilities Manager.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator that the facility failed to ensure that exit egress remained clear & unobstructed. 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 6/26/13, at 10:45 a.m., there were food carts, a freezer and a BioMed freezer within the corridor adjacent to the Cafeteria and CT Scan Room.

2. On 6/26/13, at 10:58 a.m., there were housekeeping items, a chair, a desk, a X-Ray Machine, trash, an EKG Machine, an empty hospital bed and a C-Arm Machine within the corridor adjacent to the Emergency Department.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator that the facility failed to ensure that no curtains of highly flammable character were used. This resulted in the potential for excessive fire spread (LSC 19.7.5.1). Findings include, but are not limited to:

1. On 6/26/13, at 8:51 a.m., the privacy curtains installed at the Blood Draw Station that did not have a fire spread label attached.

Based on observations and interviews it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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:

1. On 6/26/13, at 9:20 a.m., there were O2 cylinders being stored within the clean storage room in Med. Surge that had electrical outlets within 60" of the finish floor.

2. On 6/26/13, at 11:30 a.m. there were O2 cylinders being stored within the Cardio Pulmonary Room that had electrical outlets within 60" of the finish floor.

Based on observations, records review, and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, during document review between 1:00 p.m. and 6:00 p.m., there was no documentation provided to the surveyor showing an annual Med Gas Certification and no outlet testing reports.

2. On 6/25/13, at 1:23 p.m., there was an obstructed Med Gas Cabinet for the OR within the Sterile Processing Room.

Based on observations, records review, and interviews it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator that the facility failed to properly maintain the generator. 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 6/25/13, during record review between 1:00 p.m. and 6:00 p.m., there was no documentation provided to the surveyor for weekly water checks or monthly specific gravity checks on the generator. There was no documentation of a 3 yr/4 hr. load bank test on the generator. The facility had no documentation showing technician competence and access to NFPA 110 1999 edition.

2. On 6/26/13, at 12:23 p.m., the emergency shutoff for the generator was located within the generator room.

3. On 6/26/13, at 12:25 p.m., the normal vent for the generator fuel tank did not terminate a minimum of 12' above finish grade.

4. On 6/26/13, at 12:23 p.m., there was no emergency battery powered lighting within the generator enclosure.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facilities Manager and Nursing Coordinator 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 6/25/13, at 1:21 p.m., three relocatable power taps were on the floor of the OR, two of which were non-patient.

2. On 6/26/13, during the facility tour between 8:00 a.m. and 4:00 p.m., the following electrical deficiencies were found: there were three open electrical junction boxes within the mechanical penthouse; there was a junction box with flexible wiring on the floor of the mechanical penthouse; there was an obstructed electrical panel within the Nursing Office, Laboratory and Laundry Room; there was an extension cord that went through an exterior wall on the south end of the building outside Med. Surge, unknown what it is powering; there were relocatable power taps on the floor within the Laboratory, Radiology Reading Room, Medical Records Room, Med. Staff Coordinators Room, Executive Assistant's Office; there was a refrigerator plugged into a relocatable power tap in the Laboratory; there was an extension cord powering the Analyzer Machine within the Laboratory; there was an overheating transformer in Medical Records Room for a dust buster; there were non-patient relocatable power taps on the floor in the Cardio Pulmonary Room powering the Cardio Monitor and exercise equipment and in the PFT Monitor Room; there was a refrigerator and household microwave within the Cardio Pulmonary Room that was for staff use; there was a relocatable power tap being permanently used for the mechanical laundry soap machine within the Laundry and there were painted breakers within the breaker panel in the basement for the fire alarm control panel.