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Based on observations, interviews and record review through on-going dialog with the Maintenance Director it was determined that the facility failed to maintain emergency action plan current & readily available to all staff affecting the entire building. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19/18.7.1.1). Findings include, but are not limited to:

1. On 10/24/2012, the facility continued to be out of substantial compliance with the following citation: during the facility walk-through the disaster plan/emergency preparedness manual at the DNS office was reviewed and was found to be outdated and contained inaccurate and conflicting policies and procedures.

2. On 10/24/2012, the facility continued to be out of substantial compliance with the following citation: during the facility record review process, there was no documentation of an annual review of the emergency plan by the emergency preparedness committee, agreements, and procedures. The plan had been signed 5/9/2012 by the CEO, however the temporary shelter agreements were dated 9/19/2010 for Cloverleaf Hall, and 10/4/2010 for the church. A previous healthcare deputy was listed for the emergency contact for OSFM HC unit. The plan indicated to use pillows on the floor to indicate evacuated rooms and indicated to use tape to indicate evacuated rooms. The plan indicated to barricade doors with mattresses for explosions. The plan also indicated DR. Red as the code for fire and also Code Red for fire. The fire plan indicated to only evacuate patients if the fire is not extinguished and there is little or no smoke in the corridor. There was no defend in place policy to evacuate all patients from the smoke compartment containing the fire to a non-effected smoke compartment.

Based on record reviews and interviews through on-going dialog with the Maintenance Director it was determined that the facility failed to conduct fire drills. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19/18.7.1.2, A.19/18.7.1.2). Findings include, but are not limited to:

1. On 10/24/2010, the facility continued to be out of substantial compliance with the following citation: during the facility record review process, the fire drill records indicated that no drills were conducted 1st and 2nd quarter 2012 on night shift.

Based on observations, and interviews it was determined through on-going dialog with the Maintenance Director 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 19/18.3.4, 9.6). Findings include, but are not limited to:

1. On 10/24/2012, the facility continued to be out of substantial compliance with the following citation: during the facility walk-through, there was no breaker location identification at the main fire alarm control panel. There was no lock on the switch for the dry system air compressor. There was a strobe light installed in the ED patient restroom (354). There was no audible notification appliance in the Doctor sleeping room (366). There were fire alarm notification appliances installed in the X-ray room (255B) and no device installed in the X-ray control room. There were devices installed in the CT room, and the patient restroom 250, Mammography (252), in Ultrasound (245), changing rooms for imaging, 244B restroom, blood draw room 230, and restroom 236. There were devices installed in the Therapy Department between Consult 1 and 2 and in both consult rooms (137 & 138) as well as restroom 139.

On 7/25/2012 at 4:45 p.m., the Maintenance Staff, acknowledged that the fire alarm items were not installed as required by NFPA 72 private mode systems. He indicated he was unaware of the requirement and that they were compliant on previous surveys.

Based on observations, record review and interviews it was determined through on-going dialog with the Maintenance Director that the facility failed to ensure the sprinkler system is continuously maintained & in reliable operating condition for the entire building. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:

1. On 10/24/2012, the facility continued to be out of substantial compliance with the following citation: during the facility walk-through, there were no FDC signs at the fire department connections that included the buildings served by the 3 FDC's on campus.

2. On 10/24/2012, the facility continued to be out of substantial compliance with the following citation: during the facility record review process, there was no documentation of an annual forward flow test of the fire sprinkler system to ensure adequate water available for the demand of the system as designed for the previous three years.

Based on observations and interviews it was determined that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" from 40" up to 80" above the floor and no projections exceeding 4 1/2" below 40" from the floor for 3 of 4 sampled corridors of the building. 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 10/24/2012, the facility continued to be out of substantial compliance with the following citation: during the facility walk-through, there were unattended carts charging in the corridors of the patient wing by room 17 and by room 20 in the family birth center. There was a bassinet and scale in the corridor by room 20.

Based on record review and interviews it was determined through on-going dialog with the Maintenance Director that the facility failed to properly maintain the generator in accordance with NFPA 110 for the entire building emergency power supply. 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 10/24/2012, the facility continued to be out of substantial compliance with the following citation: during the facility record review process, there was no documentation of a 3 year 4 hour 80% load test of the generator since the facility was built in 2007. There was no documentation of weekly and monthly battery checks including electrolyte levels. The batteries were maintenance free and the facility had life support.