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Based on observations and interview during the survey, it was determined through on-going dialog with the Clinic Manager 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 patients & staff to hazardous products of fire (LSC 8.3.1). Findings include, but are not limited to:
1. On 10/23/13, at 3:58 p.m., there were multiple unsealed ceiling penetrations within the electrical room off the gym.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to maintain the integrity of smoke separations for egress corridors. This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of patients & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Findings include, but are not limited to:
1. On 10/23/2013, at 2:08 p.m., there was an unsealed wall penetration in storage room, door #200200 that was approximately 2" in diameter.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 19.3.6.3, Exception 2; A19.3.6.3.3). Findings include, but are not limited to:
1. On 10/22/13, at 11:06 a.m., the smoke door was missing gasket material at Door 6000 3D in RIO.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facilities Services Supervisor and Chief Engineer that the facility failed to maintain vertical openings. This resulted in the potential for the spread of fire and smoke vertically in multi-story facilities (LSC 19.3.1.1, 8.2.5.1). Findings include, but are not limited to:
1. On 10/24/13, at 5:41 a.m., the dirty dumbwaiter door in the basement decon area was stuck open and there was damage to the wall above the dumbwaiter door.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to maintain smoke barrier fire resistance ratings. This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 19.3.7.3, 19.3.75, 8.3). Findings include, but are not limited to:
1. On 10/22/2013, at 3:40 p.m., there was a round conduit penetration in the smoke barrier above the ceiling tiles adjacent to Rm. 569 that measured approximately 1/2" in diameter.
2. On 10/22/2013, at 3:50 p.m., there was a round conduit penetration in the smoke barrier above the ceiling tiles adjacent to Rm. 678 that measured approximately 1/2" in diameter and there were two unsealed penetrations above the ceiling at the cross-corridor doors adjacent to Rm. 678 around the perimeter of HVAC duct work that measured approximately 2' x 3'.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to maintain approved smoke barrier doors. This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 19.2.3.5, 8.4.1, 4.6.12.1). Findings include, but are not limited to:
1. On 10/23/13, at 9:45 a.m., there were rated suite separation doors between B and C Pods in Critical Care Unit that did not close or latch properly.
2. On 10/23/13, at 9:52 a.m., there were rated suite separation doors between C and D Pods in Critical Care Unit that did not close or latch properly.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 19.3.2). Findings include, but are not limited to:
1. On 10/23/2013, at 9:57 a.m., the door coordinator on the doors to the X-Ray Equipment storage room in the Critical Care Unit did not allow the doors to close or latch properly.
2. On 10/24/2013, at 5:40 a.m., there was a storage room, door #200092 within Minor Surgery that was not closing/latching properly.
3. On 10/24/2013, at 5:47 a.m., there was a dirty utility room, door #200122 within Recovery/SPO that did not close or latch properly.
4. On 10/24/13, at 5:42 a.m., there was a dismantled closer on a soiled linen room in Cath Lab across from an electrical room on Floor 2.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinic Manager that the facility failed to test 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 7.9). Findings include, but are not limited to:
1. On 10/23/13, at 4:00 p.m., there were egress lights that were not working in the North Stairwell Floor 1 and in Suite 102.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinic Manager that the facility failed to properly identify exits of the building. This resulted in the potential for panic and confusion during an evacuation (LSC 7.10). Findings include, but are not limited to:
1. On 10/23/13, at 4:00 p.m., there were inoperable exit signs in Suite 102 and Suite 204.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 10/22/2013, during record review between 9:00 a.m. and 5:30 p.m., the disaster plan provided by the facility to the surveyor had a Code Red Policy that did not include relocation of patients in the affected smoke compartment to the un-affected smoke compartment and used a "shelter-in-place" strategy. The RACE Policy 200.09, did not include a verbal call out on the unit floor of a "Code Red" and advised not to travel through fire and smoke doors. Facilities Fire Watch Policy did not include a requirement for having a means of communication for alerting of an emergency while on fire watch. Policy also stated that a "fire watch is not required on scheduled and /or planned interruptions of service".

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 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:
On 10/22/2013, during record review between 9:00 a.m. and 5:30 p.m., facility documentation presented to the surveyors showed that there were missing fire drills for Night shift 3rd quarter 2013.
Day shift drills for 2012-2013 were not being staggered, all drills were conducted between 7:45 a.m. and 8:00 a.m.
There were no staff rosters attached to the fire drills and there was no documentation of which staff had participated in fire drills.
Fire drill forms were incomplete, missing information such as weather, type of fire simulated, number of simulated relocated patients and specific location of simulated fire.
Documentation indicated that the "Code Red overhead page had very low volume in the Main Lobby on 3/24/13", "no overhead page heard in 6NW on 3/30/13", "could barely hear overhead page in 4 Center on 6/4/13", "weak overhead page and only announced once in 6 Center on 6/4/13" and there was no documentation of the facility having corrections made.
Documentation indicated that fire alarm strobes and chimes did not work properly or could not be heard during drills in 6 Center on 2/26/13, 6 NW on 3/30/13, 4 NW and SW on 4/11/13 and 6 Center on 6/30/13.
On 10/22/13, at 1:55 p.m., surveyor interviewed staff member, Unit Secretary #1 on Floor 6, stated that they were not instructed on checking the rooms during a drill, just instructed on closing patient room doors when the fire alarm sounded and indicated the nearest fire alarm pull station was at either end of the building, did not know about the pull station adjacent to Nurse's Station.
On 10/23/13, at 9:40 a.m., surveyor interviewed staff member, Primary Charge Nurse #1 on Floor 3, stated that they would only move the patient in the room with the fire to another smoke compartment all the other patients in the unit would be left in their rooms and protected there unless told to remove all patients and stated that the "A" in RACE is "act" not alert.
On 10/23/13, between 11:40 a.m. and 12:00 p.m., surveyors conducted a fire drill on Floor 3, West wing. Staff were observed to continue to eat within the family lounge adjacent to the elevator lobby in Center North during the drill, staff member walked by surveyor with lunch and did not react to alarm. Code red by overhead announcement stated "Main House, West Wing" and not a specific location, staff did not clear corridors in units leaving crash carts and charting stations in the corridor, there was not a clear staff member in charge in 3 West unit , overhead page in some areas were intelligible, staff in ED admitting did not hear the overhead page, notification device MHC234 (bell) was only rattling, staff asked surveyor, "where is the fire?", staff in Radiology Reception only heard "Main House, West", staff in Radiology Reception stated that they "stay put and not go through the fire doors until an All-Clear is given", staff were complacent and there was no placement of a simulated fire. On 10/23/13, between 7:45 p.m. and 8:10 p.m., a second fire drill was conducted by smoking a smoke detector in Rm. 660 on floor 6, all fire doors throughout the hospital failed to close, staff did not simulate moving of patients out of rooms to an unaffected smoke compartment, RN #1 and RN #2 stated that they would just move the patient in the fire room to an unaffected smoke compartment, staff went down both corridors in 6 West and closed patient doors not checking the rooms, staff did not mark doors, staff were complacent as RN #2 continued to work at 6 West Nurse Station. There were no fire extinguishers brought to the room, RN #3 had to be coached throughout the drill on what their responsibility was. There was no "Code Red" announcement by RN #3 when fire was discovered, there was no placement of a simulated fire, staff were complacent and did not immediately respond to the fire room after overhead page was heard by surveyor and specifically said Rm. 660.
Maintenance staff indicated that nursing staff do not know where the fire is in the unit and maintenance staff mentioned that they always find some glitch in the alarm system when they conduct drills and no record of repairs existed and staff went back to work prior to an "All-Clear" overhead announcement.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to install fire alarm system in accordance with NFPA 72 "private mode" systems. This resulted in the potential for delay and panic during fire emergencies (LSC 19.3.4, 9.6). Findings include, but are not limited to:
1. During the facility tour on 10/22/13, between 1:00 p.m. and 3:00 p.m., there were fire alarm notification devices within the RIO Practice Kitchen Rm. 500 on Floor 5, Cascade Gym Rm. 503, Patient Restroom adjacent to Rm. 537, Rehab Bath/Bedroom adjacent to Rm. 537 and Nursery in Labor and Delivery Floor 5 which are prohibited in patient treatment areas per NFPA 72 for "private mode" systems.
2. During the facility tour on 10/22/13, between 9:00 a.m. and 5:00 p.m. there were multiple fire alarm pull stations within the facility that were not installed according to NFPA 72 height requirements; locations include but are not limited to NW Stairwell on floor 5 and 6, Labor and Delivery Nursing Station and Floor 3 across from Family Lounge Rm. 345.
3. During the facility tour on 10/23/13, between 9:00 a.m. and 4:30 p.m., there were fire alarm notification devices in the Rehab/Cardio Gym and Rehab/Cardio Gym patient restroom on Floor 3, Imaging Rm. 4 and 5, Patient restroom and patient dressing room adjacent to Imaging Rm. 5, X-Ray Rm. 1, 2 and 3, Patient dressing Rm. 2, Staff/Patient Restroom in CT 2, CT Dressing Rm. 1 and 2, Nuc/Med. Injection Room, Ultrasound Room, MRI patient restroom, MRI dressing room and Endoscopy Patient restroom which are prohibited in patient treatment areas per NFPA 72 for "private mode" systems.
5. On 10/24/13, at 5:30 a.m., there was a fire alarm notification device in C-Section OR #2, Floor 5 which are prohibited in patient treatment areas per NFPA 72 for "private mode" systems.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 10/22/13, at 10:45 a.m., there was a fire alarm pull station at the NW Nurses Station on Floor 6 that was blocked by a shredded paper bin. The bin was moved away from the pull station when noted by surveyor, surveyor returned to the area the night of 10/23/13 and noted that the pull station was blocked again by the shredded paper bin.

Based on record review and interview during the survey, it was determined through on-going dialog with the Clinic Manager 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 10/23/13, during record review, 2:30 p.m. and 3:30 p.m., there was no documentation provided showing the required monthly and quarterly testing and maintenance on the fire alarm system.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinic Manager 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 (NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. On 10/23/13, at 3:41 p.m., there was an unsupervised tamper switch on a sprinkler valve at the main sprinkler riser.
2. On 10/23/13, at 3:41 p.m., there was inadequate sprinkler coverage under the NW Stair and stairwell on floor 1.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 10/22/2013, at 2:42 p.m., there was missing signage on the door leading to a fire riser room adjacent to Rm. 440.
2. On 10/23/2013, at 10:23 a.m., there was missing automatic sprinkler protection within an Electrical Imaging room, door number 200255E.
3. On 10/23/2013, at 2:39 p.m., there was missing automatic sprinkler protection under the HVAC duct work (over 48" wide) adjacent to Mechanical Room #1 North.
4. On 10/23/2013, at 3:32 p.m., there were only a total of 12 spare stock of sprinkler heads for the facility and no spare sidewall sprinkler heads (for systems with 300 to 1000, not fewer than 12 spare sprinklers or two of each type and temperature, which ever is greater; for systems over 1000, not fewer than 24 spare sprinklers or two of each type and temperature, which ever is greater).
5. On 10/24/13 at 5:43 a.m., there was no visible signage on the facilities fire department connections 6" letters red on white background stating "FDC" for approaching fire apparatus.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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. During the facility tour on 10/22/13, between 10:30 a.m. and 2:30 p.m., the following deficiencies were noted with sprinkler heads: Damaged fire sprinkler heads at the RIO Nurses station and at the RIO Equipment Wash area; painted or foreign material on heads in the SE Exit Stairwell J, Storage Room across from Room 507, Staff Restroom next to Room 515 and sprinkler head across from Room 483; missing sprinkler escutcheon rings in Staff Restroom next to Room 515.
2. During the facility tour on 10/23/13, between 10:00 a.m. and 3:30 p.m., the following deficiencies were noted with sprinkler heads: Painted or foreign material on heads in the Communications/Server Closet in the Emergency Department, Men's Shower Room in Resident Sleeping area, 3A Mechanical Room, 4A Mechanical Room and sprinkler head across from X-Ray Room 1; damaged sprinkler heads in Short Stay soiled utility room across from rooms 16-20, Imaging Waiting Room in alcove and patient restroom in Short Stay Room 14; missing sprinkler escutcheon rings in Senior Medicine Call Room 4; a covered sprinkler head with a plastic drink container in 4A Mechanical Room above AHU 10; corroded sprinkler heads in the Old Mechanical room above the Green Air Compressor and at lower basement level in Stair G.
3. On 10/24/13, at 5:20 a.m., there were missing escutcheon rings on sprinkler heads in the Decon Sink Room and Men's Locker Room Hall.
4. On 10/24/13, at 6:02 a.m., there were missing or damaged ceiling tiles in the dishwashing area of the production kitchen which could delay the activation of the sprinkler system.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Clinic Manager 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 10/23/13, during record review, between 2:30 p.m. and 3:30 p.m., there was no documentation provided showing the required weekly, monthly and quarterly testing and maintenance on the fire sprinkler system.
2. On 10/23/13, at 2:50 p.m., there were deficiencies noted on the sprinkler report dated 4/25/13 that had not been corrected. Deficiencies noted: 2 dry heads @ entry need to be replaced, an obstructed sprinkler head in the Phone Room and the outside bell did not work at the time of the test.
2. On 10/23/13, at 3:40 p.m., there were no spare sidewall sprinkler heads in the spare sprinkler cabinet and the gauges on the fire sprinkler riser were dated 1989 and were past due for replacement or recalibration since 1994.
3. On 10/23/13, between 3:42 p.m. and 4:08 p.m., there were missing escutcheon rings on sprinkler heads in the NW stairwell, Exam 9 Suite 102, Main Lobby and Reception Suite 205.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Clinic Manager 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 10/23/13, during record review between 2:30 p.m. and 3:00 p.m., the facility had not conducted the required annual forward flow test of the sprinkler system.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinic Manager 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 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:
1. On 10/23/13, between 3:52 p.m. and 4:14 p.m., there were fire extinguishers that were not inspected monthly in the Lobby Floor 1 and in non-suite areas. Clinic Manager stated those extinguishers were the responsibility of the property manager. There were fire extinguishers that were past due for inspection since June 2012 in Suite 102, fire extinguishers past due for inspection in Suite 205 since September 2007 and fire extinguisher past due for inspection in Suite 209 since September 2007.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 19.3.5.2, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:
1. On 10/23/2013, at 2:55 p.m., there was a fire extinguisher within Central Supply that was obstructed by metal carts.

Based on observations and interviews it was determined, through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to properly maintain building service equipment area and install refrigerant leak detection systems. This resulted in the potential for unexpected fire and harm to staff (LSC 19.5.2.1, 19.5.2.2, 9.2, NFPA 90A). Findings include, but are not limited to:
1. On 10/22/13, at 9:53 a.m., there was combustible storage, consisting of but not limited to a wooden door, wood fiber boards, wooden step ladder and plywood stored next to Exhaust Fan #9 on the Mechanical Floor, Floor 7.
2. On 10/23/13, at 2:40 p.m., there were missing refrigerant leak alarms at doors leading into the mechanical space housing facility chillers.

Based on record review and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to maintain an approved ventilation hood and duct system. This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 4.6.12.1, 9.2.3, 19.3.2.6, NFPA 96 A.1.1.4, UL300). Findings include, but are not limited to:
1. On 10/22/13, during record review between 9:00 a.m. and 5:30 p.m., facility documentation showed that facilities third party vendor noted that ductwork was inaccessible for cleaning, that there were broken weld joints and was leaking on 7/21/13 for both the main kitchen and Cafe. There was no documentation showing actions taken to correct these deficiencies.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with. 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. During the facility tour on 10/22/13, between 8:00 a.m. and 6:00 p.m., there were multiple wall mounted charting stations throughout Floor 6 and Floor 5 that failed to self-close.
2. On 10/22/13, at 2:16 p.m., there was an obstruction in egress Stair "I" at floor 4 consisting of a box containing empty soda containers.
3. During the facility tour on 10/23/13, between 7:00 a.m. and 5:30 p.m., there were multiple wall mounted charting stations throughout Floor 4 and Floor 3 that failed to self-close.
4. On 10/23/13, at 2:35 p.m., there were mail carts outside the mailroom blocking egress doors within the basement exit corridor.

Based on observations and interviews it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to provide safe storage for compressed gas. This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks (LSC 19.3.2.4, NFPA 99 4.3.1.1.2). Findings include, but are not limited to:
1. On 10/22/2013, between 10:20 a.m. and 2:33 p.m., there were oxygen cylinders stored in a Housekeeping Room adjacent to Rm. 687, a Clean Utility Room adjacent to Rm. 484, and Clean Supply Room 443 that had electrical outlets and switches within 60" of the finish floor.
2. On 10/23/2013, at 9:55 a.m., there were oxygen cylinders stored in the Meds Room adjacent to Rm. 475 on Floor 4 and a Storage Room (door #200200) that had electrical outlets and switches within 60" of the finish floor.
3. On 10/23/2013, at 10:00 a.m. there were 16 oxygen cylinders stored in RT Rm. 1 that did not have a door and was open to the corridor within ICU Pods.
4. On 10/24/2013, between 5:00 a.m. and 6:00 a.m., there were oxygen cylinders that were stored in Storage Rm. B and Storage Rm. C in the east/west corridor of the OR Suite and in Anesthesia/Surgery Lab adjacent to OR 3 that had electrical outlets and switches within 60" of the finish floor.
Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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, NFPA 99 4.3.1.1.2). Findings include, but are not limited to:
5. On 10/22/2013, at 1:44 p.m., there were two compressed gas cylinders that were not properly restrained from falling within the Nursery.

Based on record review and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to ensure that anesthetizing locations complied with NFPA 99, 5-4.1.1. This resulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to (ASHRAE Standard 170, 20% - 60%):
1. On 10/22/13, during record review between 9:00 a.m. and 5:30 p.m., the facility Humidity Policy 14.11 presented to the surveyors only addressed procedures dealing with a high humidity condition (above 60%). The policy did not indicate to conduct an assessment of the risk to allow a procedure to continue when the humidity is below the approved lower level of 20%. Humidity policy did not identify what adopted range standard was being used. Policy did not address what measures will be taken to ensure procedures were not completed when out of the adopted Humidity range.
2. On 10/22/13, during record review between 9:00 a.m. and 5:30 p.m., there was documentation from 7/26/13 showing a leaking medical gas outlet on Floor 6 that was repaired by facility staff and staff did not have records of technical competence with Medical Gas Systems. Facilities Medical Gas Vendor was utilizing NFPA 99 2002 edition which is not the adopted standard.

Based on observations, record review and interviews it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 10/22/2013, during record review between 9:00 a.m. and 5:30 p.m., weekly and monthly maintenance was being performed by staff and there was no documentation showing technician competency in maintaining the generator. There was no documentation to show the required 3-year / 4-hour 80% load bank test on the two generators and there was no documentation to show the required monthly specific gravity testing from 3/7/13 - 4/18/13.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinic Manager that the facility failed to ensure that that electrical wiring was maintained 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 10/23/13, at 4:11 p.m., there was an extension cord powering a shredder in the staff lounge.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to ensure that that electrical wiring & equipment was used/maintained 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. During the facility tour between 10/22/13 and 10/24/13 and between 5:00 a.m. and 6:00 p.m., there were non-patient relocatable power taps throughout the facility, locations included but not limited to, NW Nurse Station Floor 6, SW Nurse Station Floor 6, Center Nurse Station Floor 6, in the RIO Practice Kitchen Floor 5 (grow light at window), Reception Area across from Rm. 504, Labor & Delivery Nurse Station Floor 5, Nurse Station adjacent to Rm. 446 on Floor 4, Pacific NW Dialysis, 3 East 301B, 3 East 303 Stress Lab, Room 308 Pulmonary Function Test, Room 309 #1 and #2, ICU Pods, Nurse Station Floor 3, OR 2 at computer, OR 3 at computer, OR 6 at computer, OR 4 at computer, OR 8 at computer, Cath Lab 2 at suction, Cath Lab 1 at Hemographer, OR 12 at computer, OR 16 at computer, South Nurse Station in PACU, behind printer in PACU on east wall, West Nurse Station in PACU, Nurse Station in APC/Minor Surgery, APC/Minor Surgery OR 1, OR 2, OR 3, ENDO/Minor Surgery OR 5 at computer, Lasik #4 Room at computer, and Nurse Station in Recovery/SPO.
There was a damaged electrical cord on a toaster in 4 Center Clean Utility and damaged electrical outlets in Rm. 302B Equipment Cleaning, outlet 3LD20, with electrical arcing indicators on face. .
There were relocatable power taps on the floor throughout the facility, locations included but not limited to, Office Rm. 502, Office Rm. 504, Reception area across from Office Rm. 504, Pacific NW Dialysis, Clergy Room, ICU Pods and Nurse Station Floor 3, OR #15, APC Surgery Office, ENDO/Minor Surgery OR 5, Cath Lab #3 and Cath Lab #5.
There were household appliance (microwaves) in RIO Floor 6 Pantry adjacent to Rm 17, Staff Kitchen 5 East, Pantry across from Rm. 542, Rm. 307 Staff Research, Ambulatory Care Break Room (door 200014), Short Stay Breakroom, Short Stay Kitchen, Staff Lounge PACU, PACU Anesthesia Office and MIS Conference in OR's.
There were appliances plugged into relocatable power taps in 3 East Rm. 302. Space heaters and a Pill Packaging machine plugged into relocatable power taps in the Pharmacy.
There was an aquarium plugged into a relocatable power tap in East Waiting Room on Floor 5 and an permanently installed relocatable power taps in OR 2 at TV monitors.
There were non-patient relocatable power taps not in use in OR 4, on TV monitor cart in Storage A in OR area, OR 12, OR 14, Cath Lab #3 and Cath Lab #5.
There were daisy chained relocatable power taps in 3 East Rm. 302, under the desk of the Nurse Manager Rm. 150, Pharmacy Office and TelCom Room near the Resident Sleeping area.
There were missing electrical outlet covers in the TelCom Room near the Resident Sleeping area and damaged electrical power cord for the coffee maker in the Production Kitchen Break Room.

Based on record review and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facilities Services Supervisor and Chief Engineer that the facility failed to ensure that the emergency preparedness plan had written procedures to be used when the automatic fire sprinkler system is in an abnormal condition. This potentially prevents early notification of smoke &/or fire that delays evacuation of patients & staff to a safe refuge. Findings include, but are not limited to:
1. On 10/22/13, during record review between 9:00 a.m. and 5:30 p.m., the Facilities Fire Watch Policy did not include a requirement for having a means of communication for alerting of an emergency while on fire watch. Policy also stated that a "fire watch is not required on scheduled and /or planned interruptions of service".

Based on record review and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facilities Services Supervisor and Chief Engineer that the facility failed to ensure that the emergency preparedness plan had written procedures to be used when the fire alarm system is in an abnormal condition. This potentially prevents early notification of smoke &/or fire that delays evacuation of patients & staff to a safe refuge. Findings include, but are not limited to:
1. On 10/22/13, during record review between 9:00 a.m. and 5:30 p.m., the Facilities Fire Watch Policy did not include a requirement for having a means of communication for alerting of an emergency while on fire watch. Policy also stated that a "fire watch is not required on scheduled and /or planned interruptions of service".".

Based on the observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 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. On 10/22/2013, between 10:31 a.m. and 1:05 p.m., there were Alcohol Based Hand Rub station installed above a electrical outlet in the RIO Waiting Room and between electrical light switches in the Clean Utility Room on Floor 6.
2. On 10/23/2013, between 10:37 a.m. and 2:38 p.m., there were Alcohol Based Hand Rub stations installed above a light switch in Room 200022 in Ambulatory Care and Short Stay Med. Room.
3. On 10/24/2013, at 5:50 a.m., there were Alcohol Based Hand Rub stations that were installed above electrical outlets in Recovery/SPO at Bed's #3, 8 and 12.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinic Manager 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 patients & staff to hazardous products of fire (LSC 8.3.1). Findings include, but are not limited to:
1. On 10/23/13, at 3:58 p.m., there were multiple unsealed ceiling penetrations within the electrical room off the gym.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to maintain the integrity of smoke separations for egress corridors. This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of patients & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Findings include, but are not limited to:
1. On 10/23/2013, at 2:08 p.m., there was an unsealed wall penetration in storage room, door #200200 that was approximately 2" in diameter.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 19.3.6.3, Exception 2; A19.3.6.3.3). Findings include, but are not limited to:
1. On 10/22/13, at 11:06 a.m., the smoke door was missing gasket material at Door 6000 3D in RIO.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facilities Services Supervisor and Chief Engineer that the facility failed to maintain vertical openings. This resulted in the potential for the spread of fire and smoke vertically in multi-story facilities (LSC 19.3.1.1, 8.2.5.1). Findings include, but are not limited to:
1. On 10/24/13, at 5:41 a.m., the dirty dumbwaiter door in the basement decon area was stuck open and there was damage to the wall above the dumbwaiter door.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to maintain smoke barrier fire resistance ratings. This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 19.3.7.3, 19.3.75, 8.3). Findings include, but are not limited to:
1. On 10/22/2013, at 3:40 p.m., there was a round conduit penetration in the smoke barrier above the ceiling tiles adjacent to Rm. 569 that measured approximately 1/2" in diameter.
2. On 10/22/2013, at 3:50 p.m., there was a round conduit penetration in the smoke barrier above the ceiling tiles adjacent to Rm. 678 that measured approximately 1/2" in diameter and there were two unsealed penetrations above the ceiling at the cross-corridor doors adjacent to Rm. 678 around the perimeter of HVAC duct work that measured approximately 2' x 3'.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to maintain approved smoke barrier doors. This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 19.2.3.5, 8.4.1, 4.6.12.1). Findings include, but are not limited to:
1. On 10/23/13, at 9:45 a.m., there were rated suite separation doors between B and C Pods in Critical Care Unit that did not close or latch properly.
2. On 10/23/13, at 9:52 a.m., there were rated suite separation doors between C and D Pods in Critical Care Unit that did not close or latch properly.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 19.3.2). Findings include, but are not limited to:
1. On 10/23/2013, at 9:57 a.m., the door coordinator on the doors to the X-Ray Equipment storage room in the Critical Care Unit did not allow the doors to close or latch properly.
2. On 10/24/2013, at 5:40 a.m., there was a storage room, door #200092 within Minor Surgery that was not closing/latching properly.
3. On 10/24/2013, at 5:47 a.m., there was a dirty utility room, door #200122 within Recovery/SPO that did not close or latch properly.
4. On 10/24/13, at 5:42 a.m., there was a dismantled closer on a soiled linen room in Cath Lab across from an electrical room on Floor 2.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinic Manager that the facility failed to test 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 7.9). Findings include, but are not limited to:
1. On 10/23/13, at 4:00 p.m., there were egress lights that were not working in the North Stairwell Floor 1 and in Suite 102.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinic Manager that the facility failed to properly identify exits of the building. This resulted in the potential for panic and confusion during an evacuation (LSC 7.10). Findings include, but are not limited to:
1. On 10/23/13, at 4:00 p.m., there were inoperable exit signs in Suite 102 and Suite 204.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 10/22/2013, during record review between 9:00 a.m. and 5:30 p.m., the disaster plan provided by the facility to the surveyor had a Code Red Policy that did not include relocation of patients in the affected smoke compartment to the un-affected smoke compartment and used a "shelter-in-place" strategy. The RACE Policy 200.09, did not include a verbal call out on the unit floor of a "Code Red" and advised not to travel through fire and smoke doors. Facilities Fire Watch Policy did not include a requirement for having a means of communication for alerting of an emergency while on fire watch. Policy also stated that a "fire watch is not required on scheduled and /or planned interruptions of service".

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 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:
On 10/22/2013, during record review between 9:00 a.m. and 5:30 p.m., facility documentation presented to the surveyors showed that there were missing fire drills for Night shift 3rd quarter 2013.
Day shift drills for 2012-2013 were not being staggered, all drills were conducted between 7:45 a.m. and 8:00 a.m.
There were no staff rosters attached to the fire drills and there was no documentation of which staff had participated in fire drills.
Fire drill forms were incomplete, missing information such as weather, type of fire simulated, number of simulated relocated patients and specific location of simulated fire.
Documentation indicated that the "Code Red overhead page had very low volume in the Main Lobby on 3/24/13", "no overhead page heard in 6NW on 3/30/13", "could barely hear overhead page in 4 Center on 6/4/13", "weak overhead page and only announced once in 6 Center on 6/4/13" and there was no documentation of the facility having corrections made.
Documentation indicated that fire alarm strobes and chimes did not work properly or could not be heard during drills in 6 Center on 2/26/13, 6 NW on 3/30/13, 4 NW and SW on 4/11/13 and 6 Center on 6/30/13.
On 10/22/13, at 1:55 p.m., surveyor interviewed staff member, Unit Secretary #1 on Floor 6, stated that they were not instructed on checking the rooms during a drill, just instructed on closing patient room doors when the fire alarm sounded and indicated the nearest fire alarm pull station was at either end of the building, did not know about the pull station adjacent to Nurse's Station.
On 10/23/13, at 9:40 a.m., surveyor interviewed staff member, Primary Charge Nurse #1 on Floor 3, stated that they would only move the patient in the room with the fire to another smoke compartment all the other patients in the unit would be left in their rooms and protected there unless told to remove all patients and stated that the "A" in RACE is "act" not alert.
On 10/23/13, between 11:40 a.m. and 12:00 p.m., surveyors conducted a fire drill on Floor 3, West wing. Staff were observed to continue to eat within the family lounge adjacent to the elevator lobby in Center North during the drill, staff member walked by surveyor with lunch and did not react to alarm. Code red by overhead announcement stated "Main House, West Wing" and not a specific location, staff did not clear corridors in units leaving crash carts and charting stations in the corridor, there was not a clear staff member in charge in 3 West unit , overhead page in some areas were intelligible, staff in ED admitting did not hear the overhead page, notification device MHC234 (bell) was only rattling, staff asked surveyor, "where is the fire?", staff in Radiology Reception only heard "Main House, West", staff in Radiology Reception stated that they "stay put and not go through the fire doors until an All-Clear is given", staff were complacent and there was no placement of a simulated fire. On 10/23/13, between 7:45 p.m. and 8:10 p.m., a second fire drill was conducted by smoking a smoke detector in Rm. 660 on floor 6, all fire doors throughout the hospital failed to close, staff did not simulate moving of patients out of rooms to an unaffected smoke compartment, RN #1 and RN #2 stated that they would just move the patient in the fire room to an unaffected smoke compartment, staff went down both corridors in 6 West and closed patient doors not checking the rooms, staff did not mark doors, staff were complacent as RN #2 continued to work at 6 West Nurse Station. There were no fire extinguishers brought to the room, RN #3 had to be coached throughout the drill on what their responsibility was. There was no "Code Red" announcement by RN #3 when fire was discovered, there was no placement of a simulated fire, staff were complacent and did not immediately respond to the fire room after overhead page was heard by surveyor and specifically said Rm. 660.
Maintenance staff indicated that nursing staff do not know where the fire is in the unit and maintenance staff mentioned that they always find some glitch in the alarm system when they conduct drills and no record of repairs existed and staff went back to work prior to an "All-Clear" overhead announcement.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to install fire alarm system in accordance with NFPA 72 "private mode" systems. This resulted in the potential for delay and panic during fire emergencies (LSC 19.3.4, 9.6). Findings include, but are not limited to:
1. During the facility tour on 10/22/13, between 1:00 p.m. and 3:00 p.m., there were fire alarm notification devices within the RIO Practice Kitchen Rm. 500 on Floor 5, Cascade Gym Rm. 503, Patient Restroom adjacent to Rm. 537, Rehab Bath/Bedroom adjacent to Rm. 537 and Nursery in Labor and Delivery Floor 5 which are prohibited in patient treatment areas per NFPA 72 for "private mode" systems.
2. During the facility tour on 10/22/13, between 9:00 a.m. and 5:00 p.m. there were multiple fire alarm pull stations within the facility that were not installed according to NFPA 72 height requirements; locations include but are not limited to NW Stairwell on floor 5 and 6, Labor and Delivery Nursing Station and Floor 3 across from Family Lounge Rm. 345.
3. During the facility tour on 10/23/13, between 9:00 a.m. and 4:30 p.m., there were fire alarm notification devices in the Rehab/Cardio Gym and Rehab/Cardio Gym patient restroom on Floor 3, Imaging Rm. 4 and 5, Patient restroom and patient dressing room adjacent to Imaging Rm. 5, X-Ray Rm. 1, 2 and 3, Patient dressing Rm. 2, Staff/Patient Restroom in CT 2, CT Dressing Rm. 1 and 2, Nuc/Med. Injection Room, Ultrasound Room, MRI patient restroom, MRI dressing room and Endoscopy Patient restroom which are prohibited in patient treatment areas per NFPA 72 for "private mode" systems.
5. On 10/24/13, at 5:30 a.m., there was a fire alarm notification device in C-Section OR #2, Floor 5 which are prohibited in patient treatment areas per NFPA 72 for "private mode" systems.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 10/22/13, at 10:45 a.m., there was a fire alarm pull station at the NW Nurses Station on Floor 6 that was blocked by a shredded paper bin. The bin was moved away from the pull station when noted by surveyor, surveyor returned to the area the night of 10/23/13 and noted that the pull station was blocked again by the shredded paper bin.

Based on record review and interview during the survey, it was determined through on-going dialog with the Clinic Manager 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 10/23/13, during record review, 2:30 p.m. and 3:30 p.m., there was no documentation provided showing the required monthly and quarterly testing and maintenance on the fire alarm system.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinic Manager 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 (NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. On 10/23/13, at 3:41 p.m., there was an unsupervised tamper switch on a sprinkler valve at the main sprinkler riser.
2. On 10/23/13, at 3:41 p.m., there was inadequate sprinkler coverage under the NW Stair and stairwell on floor 1.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 10/22/2013, at 2:42 p.m., there was missing signage on the door leading to a fire riser room adjacent to Rm. 440.
2. On 10/23/2013, at 10:23 a.m., there was missing automatic sprinkler protection within an Electrical Imaging room, door number 200255E.
3. On 10/23/2013, at 2:39 p.m., there was missing automatic sprinkler protection under the HVAC duct work (over 48" wide) adjacent to Mechanical Room #1 North.
4. On 10/23/2013, at 3:32 p.m., there were only a total of 12 spare stock of sprinkler heads for the facility and no spare sidewall sprinkler heads (for systems with 300 to 1000, not fewer than 12 spare sprinklers or two of each type and temperature, which ever is greater; for systems over 1000, not fewer than 24 spare sprinklers or two of each type and temperature, which ever is greater).
5. On 10/24/13 at 5:43 a.m., there was no visible signage on the facilities fire department connections 6" letters red on white background stating "FDC" for approaching fire apparatus.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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. During the facility tour on 10/22/13, between 10:30 a.m. and 2:30 p.m., the following deficiencies were noted with sprinkler heads: Damaged fire sprinkler heads at the RIO Nurses station and at the RIO Equipment Wash area; painted or foreign material on heads in the SE Exit Stairwell J, Storage Room across from Room 507, Staff Restroom next to Room 515 and sprinkler head across from Room 483; missing sprinkler escutcheon rings in Staff Restroom next to Room 515.
2. During the facility tour on 10/23/13, between 10:00 a.m. and 3:30 p.m., the following deficiencies were noted with sprinkler heads: Painted or foreign material on heads in the Communications/Server Closet in the Emergency Department, Men's Shower Room in Resident Sleeping area, 3A Mechanical Room, 4A Mechanical Room and sprinkler head across from X-Ray Room 1; damaged sprinkler heads in Short Stay soiled utility room across from rooms 16-20, Imaging Waiting Room in alcove and patient restroom in Short Stay Room 14; missing sprinkler escutcheon rings in Senior Medicine Call Room 4; a covered sprinkler head with a plastic drink container in 4A Mechanical Room above AHU 10; corroded sprinkler heads in the Old Mechanical room above the Green Air Compressor and at lower basement level in Stair G.
3. On 10/24/13, at 5:20 a.m., there were missing escutcheon rings on sprinkler heads in the Decon Sink Room and Men's Locker Room Hall.
4. On 10/24/13, at 6:02 a.m., there were missing or damaged ceiling tiles in the dishwashing area of the production kitchen which could delay the activation of the sprinkler system.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Clinic Manager 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 10/23/13, during record review, between 2:30 p.m. and 3:30 p.m., there was no documentation provided showing the required weekly, monthly and quarterly testing and maintenance on the fire sprinkler system.
2. On 10/23/13, at 2:50 p.m., there were deficiencies noted on the sprinkler report dated 4/25/13 that had not been corrected. Deficiencies noted: 2 dry heads @ entry need to be replaced, an obstructed sprinkler head in the Phone Room and the outside bell did not work at the time of the test.
2. On 10/23/13, at 3:40 p.m., there were no spare sidewall sprinkler heads in the spare sprinkler cabinet and the gauges on the fire sprinkler riser were dated 1989 and were past due for replacement or recalibration since 1994.
3. On 10/23/13, between 3:42 p.m. and 4:08 p.m., there were missing escutcheon rings on sprinkler heads in the NW stairwell, Exam 9 Suite 102, Main Lobby and Reception Suite 205.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Clinic Manager 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 10/23/13, during record review between 2:30 p.m. and 3:00 p.m., the facility had not conducted the required annual forward flow test of the sprinkler system.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinic Manager 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 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:
1. On 10/23/13, between 3:52 p.m. and 4:14 p.m., there were fire extinguishers that were not inspected monthly in the Lobby Floor 1 and in non-suite areas. Clinic Manager stated those extinguishers were the responsibility of the property manager. There were fire extinguishers that were past due for inspection since June 2012 in Suite 102, fire extinguishers past due for inspection in Suite 205 since September 2007 and fire extinguisher past due for inspection in Suite 209 since September 2007.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 19.3.5.2, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:
1. On 10/23/2013, at 2:55 p.m., there was a fire extinguisher within Central Supply that was obstructed by metal carts.

Based on observations and interviews it was determined, through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to properly maintain building service equipment area and install refrigerant leak detection systems. This resulted in the potential for unexpected fire and harm to staff (LSC 19.5.2.1, 19.5.2.2, 9.2, NFPA 90A). Findings include, but are not limited to:
1. On 10/22/13, at 9:53 a.m., there was combustible storage, consisting of but not limited to a wooden door, wood fiber boards, wooden step ladder and plywood stored next to Exhaust Fan #9 on the Mechanical Floor, Floor 7.
2. On 10/23/13, at 2:40 p.m., there were missing refrigerant leak alarms at doors leading into the mechanical space housing facility chillers.

Based on record review and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to maintain an approved ventilation hood and duct system. This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 4.6.12.1, 9.2.3, 19.3.2.6, NFPA 96 A.1.1.4, UL300). Findings include, but are not limited to:
1. On 10/22/13, during record review between 9:00 a.m. and 5:30 p.m., facility documentation showed that facilities third party vendor noted that ductwork was inaccessible for cleaning, that there were broken weld joints and was leaking on 7/21/13 for both the main kitchen and Cafe. There was no documentation showing actions taken to correct these deficiencies.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with. 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. During the facility tour on 10/22/13, between 8:00 a.m. and 6:00 p.m., there were multiple wall mounted charting stations throughout Floor 6 and Floor 5 that failed to self-close.
2. On 10/22/13, at 2:16 p.m., there was an obstruction in egress Stair "I" at floor 4 consisting of a box containing empty soda containers.
3. During the facility tour on 10/23/13, between 7:00 a.m. and 5:30 p.m., there were multiple wall mounted charting stations throughout Floor 4 and Floor 3 that failed to self-close.
4. On 10/23/13, at 2:35 p.m., there were mail carts outside the mailroom blocking egress doors within the basement exit corridor.

Based on observations and interviews it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to provide safe storage for compressed gas. This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks (LSC 19.3.2.4, NFPA 99 4.3.1.1.2). Findings include, but are not limited to:
1. On 10/22/2013, between 10:20 a.m. and 2:33 p.m., there were oxygen cylinders stored in a Housekeeping Room adjacent to Rm. 687, a Clean Utility Room adjacent to Rm. 484, and Clean Supply Room 443 that had electrical outlets and switches within 60" of the finish floor.
2. On 10/23/2013, at 9:55 a.m., there were oxygen cylinders stored in the Meds Room adjacent to Rm. 475 on Floor 4 and a Storage Room (door #200200) that had electrical outlets and switches within 60" of the finish floor.
3. On 10/23/2013, at 10:00 a.m. there were 16 oxygen cylinders stored in RT Rm. 1 that did not have a door and was open to the corridor within ICU Pods.
4. On 10/24/2013, between 5:00 a.m. and 6:00 a.m., there were oxygen cylinders that were stored in Storage Rm. B and Storage Rm. C in the east/west corridor of the OR Suite and in Anesthesia/Surgery Lab adjacent to OR 3 that had electrical outlets and switches within 60" of the finish floor.
Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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, NFPA 99 4.3.1.1.2). Findings include, but are not limited to:
5. On 10/22/2013, at 1:44 p.m., there were two compressed gas cylinders that were not properly restrained from falling within the Nursery.

Based on record review and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to ensure that anesthetizing locations complied with NFPA 99, 5-4.1.1. This resulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to (ASHRAE Standard 170, 20% - 60%):
1. On 10/22/13, during record review between 9:00 a.m. and 5:30 p.m., the facility Humidity Policy 14.11 presented to the surveyors only addressed procedures dealing with a high humidity condition (above 60%). The policy did not indicate to conduct an assessment of the risk to allow a procedure to continue when the humidity is below the approved lower level of 20%. Humidity policy did not identify what adopted range standard was being used. Policy did not address what measures will be taken to ensure procedures were not completed when out of the adopted Humidity range.
2. On 10/22/13, during record review between 9:00 a.m. and 5:30 p.m., there was documentation from 7/26/13 showing a leaking medical gas outlet on Floor 6 that was repaired by facility staff and staff did not have records of technical competence with Medical Gas Systems. Facilities Medical Gas Vendor was utilizing NFPA 99 2002 edition which is not the adopted standard.

Based on observations, record review and interviews it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer 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 10/22/2013, during record review between 9:00 a.m. and 5:30 p.m., weekly and monthly maintenance was being performed by staff and there was no documentation showing technician competency in maintaining the generator. There was no documentation to show the required 3-year / 4-hour 80% load bank test on the two generators and there was no documentation to show the required monthly specific gravity testing from 3/7/13 - 4/18/13.

Based on observations and interview during the survey, it was determined through on-going dialog with the Clinic Manager that the facility failed to ensure that that electrical wiring was maintained 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 10/23/13, at 4:11 p.m., there was an extension cord powering a shredder in the staff lounge.

Based on observations and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facility Services Supervisor and Chief Engineer that the facility failed to ensure that that electrical wiring & equipment was used/maintained 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. During the facility tour between 10/22/13 and 10/24/13 and between 5:00 a.m. and 6:00 p.m., there were non-patient relocatable power taps throughout the facility, locations included but not limited to, NW Nurse Station Floor 6, SW Nurse Station Floor 6, Center Nurse Station Floor 6, in the RIO Practice Kitchen Floor 5 (grow light at window), Reception Area across from Rm. 504, Labor & Delivery Nurse Station Floor 5, Nurse Station adjacent to Rm. 446 on Floor 4, Pacific NW Dialysis, 3 East 301B, 3 East 303 Stress Lab, Room 308 Pulmonary Function Test, Room 309 #1 and #2, ICU Pods, Nurse Station Floor 3, OR 2 at computer, OR 3 at computer, OR 6 at computer, OR 4 at computer, OR 8 at computer, Cath Lab 2 at suction, Cath Lab 1 at Hemographer, OR 12 at computer, OR 16 at computer, South Nurse Station in PACU, behind printer in PACU on east wall, West Nurse Station in PACU, Nurse Station in APC/Minor Surgery, APC/Minor Surgery OR 1, OR 2, OR 3, ENDO/Minor Surgery OR 5 at computer, Lasik #4 Room at computer, and Nurse Station in Recovery/SPO.
There was a damaged electrical cord on a toaster in 4 Center Clean Utility and damaged electrical outlets in Rm. 302B Equipment Cleaning, outlet 3LD20, with electrical arcing indicators on face. .
There were relocatable power taps on the floor throughout the facility, locations included but not limited to, Office Rm. 502, Office Rm. 504, Reception area across from Office Rm. 504, Pacific NW Dialysis, Clergy Room, ICU Pods and Nurse Station Floor 3, OR #15, APC Surgery Office, ENDO/Minor Surgery OR 5, Cath Lab #3 and Cath Lab #5.
There were household appliance (microwaves) in RIO Floor 6 Pantry adjacent to Rm 17, Staff Kitchen 5 East, Pantry across from Rm. 542, Rm. 307 Staff Research, Ambulatory Care Break Room (door 200014), Short Stay Breakroom, Short Stay Kitchen, Staff Lounge PACU, PACU Anesthesia Office and MIS Conference in OR's.
There were appliances plugged into relocatable power taps in 3 East Rm. 302. Space heaters and a Pill Packaging machine plugged into relocatable power taps in the Pharmacy.
There was an aquarium plugged into a relocatable power tap in East Waiting Room on Floor 5 and an permanently installed relocatable power taps in OR 2 at TV monitors.
There were non-patient relocatable power taps not in use in OR 4, on TV monitor cart in Storage A in OR area, OR 12, OR 14, Cath Lab #3 and Cath Lab #5.
There were daisy chained relocatable power taps in 3 East Rm. 302, under the desk of the Nurse Manager Rm. 150, Pharmacy Office and TelCom Room near the Resident Sleeping area.
There were missing electrical outlet covers in the TelCom Room near the Resident Sleeping area and damaged electrical power cord for the coffee maker in the Production Kitchen Break Room.

Based on record review and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facilities Services Supervisor and Chief Engineer that the facility failed to ensure that the emergency preparedness plan had written procedures to be used when the automatic fire sprinkler system is in an abnormal condition. This potentially prevents early notification of smoke &/or fire that delays evacuation of patients & staff to a safe refuge. Findings include, but are not limited to:
1. On 10/22/13, during record review between 9:00 a.m. and 5:30 p.m., the Facilities Fire Watch Policy did not include a requirement for having a means of communication for alerting of an emergency while on fire watch. Policy also stated that a "fire watch is not required on scheduled and /or planned interruptions of service".

Based on record review and interview during the survey, it was determined through on-going dialog with the Operations Manager, Facilities Services Supervisor and Chief Engineer that the facility failed to ensure that the emergency preparedness plan had written procedures to be used when the fire alarm system is in an abnormal condition. This potentially prevents early notification of smoke &/or fire that delays evacuation of patients & staff to a safe refuge. Findings include, but are not limited to:
1. On 10/22/13, during record review between 9:00 a.m. and 5:30 p.m., the Facilities Fire Watch Policy did not include a requirement for having a means of communication for alerting of an emergency while on fire watch. Policy also stated that a "fire watch is not required on scheduled and /or planned interruptions of service".".