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Based on observations and interview during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to separate sections of health care facilities from non-healthcare facilities.
This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 18.1.2.3, 18.1.1.4, 18.1.2.3).
Findings include, but are not limited to:
1. On 4/8/2015, at 9:42 a.m., the rated doors within the 2-hr. wall between the I-2 Occupancy and the B-Occupancy failed to latch in a closed position when placed on the doors synchronizer. Doors are located behind the Central Processing Sterilizers.
2. On 4/8/2015, at 9:45 a.m., there was a unsealed penetration within the 2-hr. wall between the I-2 Occupancy and the B-Occupancy adjacent to the Physicians Lounge that was located around an 8" HVAC duct.

Based on observations and interview during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to maintain the integrity of smoke separations for the building.
This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5).
Findings include, but are not limited to:
1. On 4/8/2015, at 11:05 a.m., there were unsealed wall penetrations and non-completed 2-hr. assembly for the wall between the Family Birthing Center Lobby and Emergency Department.

Based on observations and interview during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to maintain the integrity of smoke separations.
This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 18.3.6.1, .2, .5).
Findings include, but are not limited to:
1. On 4/8/2015, between 7:52 a.m. and 8:00 a.m., there was missing fire protective coating on the structural steel members within the North and South penthouse's that appeared to be removed by the relocation of equipment mounting brackets.
2. On 4/8/2015, at 8:15 a.m., there were unsealed wall penetrations between the wall of the North Stairwell and the North Penthouse that were approximately 1/2" in size and a horizontal and vertical penetration along the edge of pieces of drywall.
3. On 4/8/2015, at 8:52 a.m., there was an unsealed edge at the bottom of the drywall along the 2-hr separation wall within the 3rd floor IT Room in the North Clean Equipment room.
4. On 4/8/2015, at 10:14 a.m., there was missing fire protective coating on the structural steel members within the AHU2 Mechanical room that appeared to be removed by the relocation of equipment mounting brackets.

Based on observations, document review and interviews during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to provide two smoke compartments on each floor or fire area for new buildings (18.3.7.1, 18.3.7.2).
This resulted in the potential for facility to not be able to use the defend in place concept.
Findings include, but are not limited to:
1. On 4/9/2015, at 11:10 a.m., during a fire drill conducted by the surveyors on the 3rd floor of the facility, the Won-Door that provides the separation for two smoke compartments on the floor did not function when staff pulled the fire alarm pull station on the 3rd floor.
Surveyor's asked for a fire alarm matrix to show what devices would activate the Won-Door but fire alarm matrix was not available. Facility staff indicated that the only device that would activate the Won-Door would be the existing smoke detectors on either side of the Won-Door.
Smoke detection within patient room's or water flow activation would also not activate the Won-Door on the 3rd floor. Without the activation of the Won-Door by any notification devices, initiating devices or water flow devices, the 3rd floor would not be divided into two smoke compartments as specified in NFPA 101, Chapter 18.

Based on interviews and record review during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to maintain emergency preparedness plan current & readily available to all staff, affecting the entire building.
This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 18.7.1.1).
Findings include, but are not limited to:
1. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the disaster plan provided by the facility to the surveyor did not have an annual review date only review dates on specific policies and procedures.
Facilities policy states; "the annual review of the Emergency Operations Plan will be conducted 60 days after every new calendar year". The facility did not have complete documentation of an annual Hazard Vulnerability Assessment specific to hazards/emergencies that would be encountered by the facility.
2. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the facility did not have current transfer agreements with equivalent facilities, documents provided were dated 10/2013 for Ochoco Care, 11/2011 for Redmond Surgery Center, 7/2011 for Bend Surgery Center and 6/2011 for Cascade Surgicenter and were past due since 10/2014, 11/2012, 7/2012 and 6/2012.
3. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the facility did not have current transportation agreements, documents provided were dated 8/2011 for Crook County School District, 8/2011 for Redmond School District and 7/2011 for Bend/La Pine School District and were past due since 8/2012 and 7/2012.
4. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the disaster plan provided by the facility to the surveyor did not have a facility map showing the physical locations of utility shutoffs (electric, gas, water, etc.) in the event the utilities needed to be shut down during/after an emergency event.

Based on interviews and record review during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to maintain emergency preparedness plan current & readily available to all staff, affecting the entire building.
This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1).
Findings include, but are not limited to:
1. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the disaster plan provided by the facility to the surveyor did not have an annual review date only review dates on specific policies and procedures.
Facilities policy states; "the annual review of the Emergency Operations Plan will be conducted 60 days after every new calendar year". The facility did not have complete documentation of an annual Hazard Vulnerability Assessment specific to hazards/emergencies that would be encountered by the facility.
2. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the facility did not have current transfer agreements with equivalent facilities, documents provided were dated 10/2013 for Ochoco Care, 11/2011 for Redmond Surgery Center, 7/2011 for Bend Surgery Center and 6/2011 for Cascade Surgicenter and were past due since 10/2014, 11/2012, 7/2012 and 6/2012.
3. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the facility did not have current transportation agreements, documents provided were dated 8/2011 for Crook County School District, 8/2011 for Redmond School District and 7/2011 for Bend/La Pine School District and were past due since 8/2012 and 7/2012.
4. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the disaster plan provided by the facility to the surveyor did not have a facility map showing the physical locations of utility shutoffs (electric, gas, water, etc.) in the event the utilities needed to be shut down during/after an emergency event.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to provide fire drills for all staff affecting the entire building.
This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 18.7.1.2, A.18.7.1.2).
Findings include, but are not limited to:
1. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the facility had no documentation on conducting their 1st quarter night shift fire drills for 2015.
2. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility.
Fire drill forms were missing items such as: type of simulated fire, number of simulated evacuated patients from the affected smoke compartment to the unaffected smoke compartment, time to complete the simulated patient evacuation from the affected smoke compartment to the unaffected smoke compartment, location of simulated fire, list of staff participating in the drill, and staff performance.
3. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., facility documentation presented to the surveyor showed that fire drills for night shift in 2014 and 2015 were not being staggered throughout the entire shift. Fire drills were conducted between 11:05 p.m. and 11:55 p.m.
4. On 4/9/2015, at 11:10 a.m., surveyor's conducted a fire drill on the 3rd floor of the facility. Staff did not simulate the evacuation of patients within the affected smoke compartment to the unaffected smoke compartment, fire alarm was silenced during the drill which caused staff to not continue with the fire drill when the drill was not complete, floor 2 staff did not clear corridors or ready the unit for incoming patients and the Won-Door on the third floor did not operate on the activation of a fire alarm pull station on the 3rd floor.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to provide fire drills for all staff affecting the entire building.
This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2).
Findings include, but are not limited to:
1. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the facility had no documentation on conducting their 1st quarter night shift fire drill for 2015.
2. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility.
Fire drill forms were missing items such as: type of simulated fire, number of simulated evacuated patients from the affected smoke compartment to the unaffected smoke compartment, time to complete the simulated patient evacuation from the affected smoke compartment to the unaffected smoke compartment, location of simulated fire, list of staff participating in the drill, and staff performance.
3. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., facility documentation presented to the surveyor showed that fire drills for night shift in 2014 and 2015 were not being staggered throughout the entire shift. Fire drills were conducted between 11:05 p.m. and 11:55 p.m.
4. On 4/9/2015, at 11:10 a.m., surveyor's conducted a fire drill on the 3rd floor of the facility. Staff did not simulate the evacuation of patients within the affected smoke compartment to the unaffected smoke compartment, fire alarm was silenced during the drill and staff and surveyor's thought the drill was complete when the drill was not complete, floor 2 staff did not clear corridors or ready the unit for incoming patients and the Won-Door on the third floor did not operate on the activation of a fire alarm pull station on the 3rd floor.

Based on observations and interview during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff 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 of patients during fire emergencies (LSC 18.3.4, 9.6).
Findings include, but are not limited to:
1. On 4/9/2015, during the facility tour between 9:00 a.m. and 12:00 p.m., notification appliances (fire alarm strobes) were installed within Patient Rooms on the 2nd and 3rd floors 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 CEO, Safety Director and Engineering Services Staff that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13.
This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 19.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25).
Findings include, but are not limited to:
1. On 4/8/2015, at 10:59 a.m., there was missing automatic sprinkler protection on an exterior overhang constructed of combustible materials that measured approximately 50" in width outside of the C-Section exit on the East side of the building.
2. On 4/8/2015, at 11:02 a.m., there was missing automatic sprinkler protection on an exterior overhang constructed of combustible materials outside of the Family Birthing Center entrance canopy.

Based on observations and interview during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition for the entire building.
This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6).
Findings include, but are not limited to:
1. On 4/8/2015, at 10:59 a.m., there was a painted automatic sprinkler head within the 1950 Family Birthing Center Lobby entrance that needs to be replaced.

Based on observations and interview during the survey, it was determined through on-going dialog with the Safety Director and Engineering Services Staff that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition.
This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6).
Findings include, but are not limited to:
1. On 4/8/2015, at 8:06 a.m., there was a painted automatic sprinkler head within the North stairwell on the 3rd floor landing that needs to be replaced.
2. On 4/8/2015, at 8:50 a.m., there were damaged automatic sprinkler heads within the 3rd floor Clean Equipment Room that need to be replaced.
3. On 4/8/2015, at 8:51 a.m., there was a damaged automatic sprinkler head within the bathroom of Patient Rm. 310 that needs to be replaced.
4. On 4/8/2015, at 9:12 a.m., there was a painted automatic sprinkler head within the bathroom of Patient Rm. 266 that needs to be replaced.
5. On 4/8/2015, at 10:15 a.m., there was a damaged automatic sprinkler head within the OR Sterile Corridor adjacent to the OR Lounge that needs to be replaced.

Based on observations and interview during the survey, it was determined through on-going dialog with the Safety Director and Engineering Services Staff that the facility failed to maintain fire extinguishers in accordance with adopted standards for fire extinguishers.
This resulted in the potential for fires to progress beyond incipient stage (LSC 18.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10).
Findings include, but are not limited to:
1. On 4/7/2015, at 5:01 p.m., there was a missing minimum sized 10A 120B fire extinguisher for the Hospital's exterior Heliport (H-2 category aircraft, 50' - 80' tail-boom to rotors).

Based on observations and interview during the survey, it was determined through on-going dialog with the Safety Director and Engineering Services Staff that the facility failed to maintain fire extinguishers in accordance with adopted standards for fire extinguishers.
This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10).
Findings include, but are not limited to:
1. On 4/7/2015, at 5:01 p.m., there was a missing minimum sized 10A 120B fire extinguisher for the Hospital's exterior Heliport (H-2 category aircraft, 50' - 80' tail-boom to rotors).

Based on observations and interview during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to ensure that no curtains of highly flammable character were used within the building.
This resulted in the potential for excessive fire spread (LSC 19.7.5.1).
Findings include, but are not limited to:
1. On 4/8/2015, between 10:30 a.m. and 11:30 a.m., there were shower curtains within Patient Rooms in the Family Birthing Unit that lacked documentation of being constructed or treated for fire resistance.
Patient rooms include but not limited to: Rm. 108, 109, 110, 112, 115, 120, and SANE Exam room.
2. On 4/8/2015, at 1:13 p.m., the privacy curtain within the ER Decontamination room had mesh at the top of the curtain that did not meet fire code standards.

Based on observations and interviews it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff 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 in the medical gas storage room. (LSC 19.3.2.4, NFPA 99 4.3.1.1.2).
Findings include, but are not limited to:
1. On 4/8/2015, at 1:57 p.m., there was electrical outlets and switches within 60" of the finish floor within the exterior medical compressed gas storage room of the building.

Based on record review and interviews during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1.
This resulted in the potential for injury to patients during medical procedures.
Findings include, but are not limited to:
1. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., facility documentation provided showed that humidity levels for anesthetizing locations was not being logged prior to the beginning of procedures and only being logged at the beginning of the day's first procedure.

Facility staff explained that the humidity was being monitored by an electronic system but facility was unable to provide documentation showing the monitoring of the humidity.

Based on record review and interviews during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1.
This resulted in the potential for injury to patients during medical procedures.
Findings include, but are not limited to:
1. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., facility documentation provided showed that humidity levels for anesthetizing locations was not being logged prior to the beginning of procedures and only being logged at the beginning of the day's first procedure.
Facility staff explained that the humidity was being monitored by an electronic system but facility was unable to provide documentation showing the monitoring of the humidity.

Based on observations and interview during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70.
This resulted in the potential for injury to residents & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 4/8/2015, at 8:11 a.m., there were multiple electrical conduits that were observed to be broken or cracked on the 1980 building roof for exhaust hood fans. Exhaust hood fans included but not limited to: EF3, EF4, and EF18.
2. On 4/8/2015, during the facility tour between 10:39 a.m. and 11:30 a.m., there were broken electrical outlets within the Family Birthing Center rooms. Family Birthing Center rooms included but not limited to: Rm. 108, Rm. 109, and Rm. 114.
3. On 4/8/2015, at 10:50 a.m., there were 2 patient type relocatable power taps (RPT's) that were permanently attached to the building within the Ante Nursery Rm.
4. On 4/8/2015, at 2:03 p.m., there was a power strip on the floor within the Lock Smith Office that was located behind the work bench and was exposed to metal shards created by the Key Cutting machine.
5. On 4/8/2015, at 2:03 p.m., there were electrical outlets located within the Lock Smith Office that were located behind the work bench and were exposed to metal shards created by the Key Cutting machine.

Based on observations and interview during the survey, it was determined through on-going dialog with the Safety Director and Engineering Services Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70.
This resulted in the potential for injury to residents & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 4/8/2015, at 8:40 a.m., there was a relocatable power tap (RPT) on the floor within the Med. Surge Office, Floor 3.
2. On 4/8/2015, at 8:54 a.m., there were 2-relocatable power taps (RPT's) on the floor within the Hospitalist Room, Floor 2.
3. On 4/8/2015, at 9:00 a.m., there was a power cord for the Crash Cart within the 2nd floor Nurse Work Area that was being compressed by the corner of a metal cart.
4. On 4/8/2015, at 9:14 a.m., there were multiple relocatable power taps (RPT's) on the floor within the Nurse Station Cubicles on Floor 2 and Floor 3.

Based on the observations and interview during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to install alcohol based hand rub (ABHR) dispensers away from sources of ignition.
This resulted in the potential for injury to residents and staff (LSC 19.3.2.6, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623).
Findings include, but are not limited to:
1. On 4/8/2015, at 10:50 a.m., there was an Alcohol Based Hand Rub (ABHR) dispenser installed above an electrical plug within the Ante Nursery Rm.

Based on observations and interview during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to separate sections of health care facilities from non-healthcare facilities.
This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 18.1.2.3, 18.1.1.4, 18.1.2.3).
Findings include, but are not limited to:
1. On 4/8/2015, at 9:42 a.m., the rated doors within the 2-hr. wall between the I-2 Occupancy and the B-Occupancy failed to latch in a closed position when placed on the doors synchronizer. Doors are located behind the Central Processing Sterilizers.
2. On 4/8/2015, at 9:45 a.m., there was a unsealed penetration within the 2-hr. wall between the I-2 Occupancy and the B-Occupancy adjacent to the Physicians Lounge that was located around an 8" HVAC duct.

Based on observations and interview during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to maintain the integrity of smoke separations for the building.
This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5).
Findings include, but are not limited to:
1. On 4/8/2015, at 11:05 a.m., there were unsealed wall penetrations and non-completed 2-hr. assembly for the wall between the Family Birthing Center Lobby and Emergency Department.

Based on observations and interview during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to maintain the integrity of smoke separations.
This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 18.3.6.1, .2, .5).
Findings include, but are not limited to:
1. On 4/8/2015, between 7:52 a.m. and 8:00 a.m., there was missing fire protective coating on the structural steel members within the North and South penthouse's that appeared to be removed by the relocation of equipment mounting brackets.
2. On 4/8/2015, at 8:15 a.m., there were unsealed wall penetrations between the wall of the North Stairwell and the North Penthouse that were approximately 1/2" in size and a horizontal and vertical penetration along the edge of pieces of drywall.
3. On 4/8/2015, at 8:52 a.m., there was an unsealed edge at the bottom of the drywall along the 2-hr separation wall within the 3rd floor IT Room in the North Clean Equipment room.
4. On 4/8/2015, at 10:14 a.m., there was missing fire protective coating on the structural steel members within the AHU2 Mechanical room that appeared to be removed by the relocation of equipment mounting brackets.

Based on observations, document review and interviews during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to provide two smoke compartments on each floor or fire area for new buildings (18.3.7.1, 18.3.7.2).
This resulted in the potential for facility to not be able to use the defend in place concept.
Findings include, but are not limited to:
1. On 4/9/2015, at 11:10 a.m., during a fire drill conducted by the surveyors on the 3rd floor of the facility, the Won-Door that provides the separation for two smoke compartments on the floor did not function when staff pulled the fire alarm pull station on the 3rd floor.
Surveyor's asked for a fire alarm matrix to show what devices would activate the Won-Door but fire alarm matrix was not available. Facility staff indicated that the only device that would activate the Won-Door would be the existing smoke detectors on either side of the Won-Door.
Smoke detection within patient room's or water flow activation would also not activate the Won-Door on the 3rd floor. Without the activation of the Won-Door by any notification devices, initiating devices or water flow devices, the 3rd floor would not be divided into two smoke compartments as specified in NFPA 101, Chapter 18.

Based on interviews and record review during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to maintain emergency preparedness plan current & readily available to all staff, affecting the entire building.
This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 18.7.1.1).
Findings include, but are not limited to:
1. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the disaster plan provided by the facility to the surveyor did not have an annual review date only review dates on specific policies and procedures.
Facilities policy states; "the annual review of the Emergency Operations Plan will be conducted 60 days after every new calendar year". The facility did not have complete documentation of an annual Hazard Vulnerability Assessment specific to hazards/emergencies that would be encountered by the facility.
2. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the facility did not have current transfer agreements with equivalent facilities, documents provided were dated 10/2013 for Ochoco Care, 11/2011 for Redmond Surgery Center, 7/2011 for Bend Surgery Center and 6/2011 for Cascade Surgicenter and were past due since 10/2014, 11/2012, 7/2012 and 6/2012.
3. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the facility did not have current transportation agreements, documents provided were dated 8/2011 for Crook County School District, 8/2011 for Redmond School District and 7/2011 for Bend/La Pine School District and were past due since 8/2012 and 7/2012.
4. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the disaster plan provided by the facility to the surveyor did not have a facility map showing the physical locations of utility shutoffs (electric, gas, water, etc.) in the event the utilities needed to be shut down during/after an emergency event.

Based on interviews and record review during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to maintain emergency preparedness plan current & readily available to all staff, affecting the entire building.
This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1).
Findings include, but are not limited to:
1. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the disaster plan provided by the facility to the surveyor did not have an annual review date only review dates on specific policies and procedures.
Facilities policy states; "the annual review of the Emergency Operations Plan will be conducted 60 days after every new calendar year". The facility did not have complete documentation of an annual Hazard Vulnerability Assessment specific to hazards/emergencies that would be encountered by the facility.
2. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the facility did not have current transfer agreements with equivalent facilities, documents provided were dated 10/2013 for Ochoco Care, 11/2011 for Redmond Surgery Center, 7/2011 for Bend Surgery Center and 6/2011 for Cascade Surgicenter and were past due since 10/2014, 11/2012, 7/2012 and 6/2012.
3. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the facility did not have current transportation agreements, documents provided were dated 8/2011 for Crook County School District, 8/2011 for Redmond School District and 7/2011 for Bend/La Pine School District and were past due since 8/2012 and 7/2012.
4. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the disaster plan provided by the facility to the surveyor did not have a facility map showing the physical locations of utility shutoffs (electric, gas, water, etc.) in the event the utilities needed to be shut down during/after an emergency event.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to provide fire drills for all staff affecting the entire building.
This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 18.7.1.2, A.18.7.1.2).
Findings include, but are not limited to:
1. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the facility had no documentation on conducting their 1st quarter night shift fire drills for 2015.
2. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility.
Fire drill forms were missing items such as: type of simulated fire, number of simulated evacuated patients from the affected smoke compartment to the unaffected smoke compartment, time to complete the simulated patient evacuation from the affected smoke compartment to the unaffected smoke compartment, location of simulated fire, list of staff participating in the drill, and staff performance.
3. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., facility documentation presented to the surveyor showed that fire drills for night shift in 2014 and 2015 were not being staggered throughout the entire shift. Fire drills were conducted between 11:05 p.m. and 11:55 p.m.
4. On 4/9/2015, at 11:10 a.m., surveyor's conducted a fire drill on the 3rd floor of the facility. Staff did not simulate the evacuation of patients within the affected smoke compartment to the unaffected smoke compartment, fire alarm was silenced during the drill which caused staff to not continue with the fire drill when the drill was not complete, floor 2 staff did not clear corridors or ready the unit for incoming patients and the Won-Door on the third floor did not operate on the activation of a fire alarm pull station on the 3rd floor.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to provide fire drills for all staff affecting the entire building.
This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2).
Findings include, but are not limited to:
1. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., the facility had no documentation on conducting their 1st quarter night shift fire drill for 2015.
2. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility.
Fire drill forms were missing items such as: type of simulated fire, number of simulated evacuated patients from the affected smoke compartment to the unaffected smoke compartment, time to complete the simulated patient evacuation from the affected smoke compartment to the unaffected smoke compartment, location of simulated fire, list of staff participating in the drill, and staff performance.
3. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., facility documentation presented to the surveyor showed that fire drills for night shift in 2014 and 2015 were not being staggered throughout the entire shift. Fire drills were conducted between 11:05 p.m. and 11:55 p.m.
4. On 4/9/2015, at 11:10 a.m., surveyor's conducted a fire drill on the 3rd floor of the facility. Staff did not simulate the evacuation of patients within the affected smoke compartment to the unaffected smoke compartment, fire alarm was silenced during the drill and staff and surveyor's thought the drill was complete when the drill was not complete, floor 2 staff did not clear corridors or ready the unit for incoming patients and the Won-Door on the third floor did not operate on the activation of a fire alarm pull station on the 3rd floor.

Based on observations and interview during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff 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 of patients during fire emergencies (LSC 18.3.4, 9.6).
Findings include, but are not limited to:
1. On 4/9/2015, during the facility tour between 9:00 a.m. and 12:00 p.m., notification appliances (fire alarm strobes) were installed within Patient Rooms on the 2nd and 3rd floors 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 CEO, Safety Director and Engineering Services Staff that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13.
This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 19.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25).
Findings include, but are not limited to:
1. On 4/8/2015, at 10:59 a.m., there was missing automatic sprinkler protection on an exterior overhang constructed of combustible materials that measured approximately 50" in width outside of the C-Section exit on the East side of the building.
2. On 4/8/2015, at 11:02 a.m., there was missing automatic sprinkler protection on an exterior overhang constructed of combustible materials outside of the Family Birthing Center entrance canopy.

Based on observations and interview during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition for the entire building.
This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6).
Findings include, but are not limited to:
1. On 4/8/2015, at 10:59 a.m., there was a painted automatic sprinkler head within the 1950 Family Birthing Center Lobby entrance that needs to be replaced.

Based on observations and interview during the survey, it was determined through on-going dialog with the Safety Director and Engineering Services Staff that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition.
This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6).
Findings include, but are not limited to:
1. On 4/8/2015, at 8:06 a.m., there was a painted automatic sprinkler head within the North stairwell on the 3rd floor landing that needs to be replaced.
2. On 4/8/2015, at 8:50 a.m., there were damaged automatic sprinkler heads within the 3rd floor Clean Equipment Room that need to be replaced.
3. On 4/8/2015, at 8:51 a.m., there was a damaged automatic sprinkler head within the bathroom of Patient Rm. 310 that needs to be replaced.
4. On 4/8/2015, at 9:12 a.m., there was a painted automatic sprinkler head within the bathroom of Patient Rm. 266 that needs to be replaced.
5. On 4/8/2015, at 10:15 a.m., there was a damaged automatic sprinkler head within the OR Sterile Corridor adjacent to the OR Lounge that needs to be replaced.

Based on observations and interview during the survey, it was determined through on-going dialog with the Safety Director and Engineering Services Staff that the facility failed to maintain fire extinguishers in accordance with adopted standards for fire extinguishers.
This resulted in the potential for fires to progress beyond incipient stage (LSC 18.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10).
Findings include, but are not limited to:
1. On 4/7/2015, at 5:01 p.m., there was a missing minimum sized 10A 120B fire extinguisher for the Hospital's exterior Heliport (H-2 category aircraft, 50' - 80' tail-boom to rotors).

Based on observations and interview during the survey, it was determined through on-going dialog with the Safety Director and Engineering Services Staff that the facility failed to maintain fire extinguishers in accordance with adopted standards for fire extinguishers.
This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10).
Findings include, but are not limited to:
1. On 4/7/2015, at 5:01 p.m., there was a missing minimum sized 10A 120B fire extinguisher for the Hospital's exterior Heliport (H-2 category aircraft, 50' - 80' tail-boom to rotors).

Based on observations and interview during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to ensure that no curtains of highly flammable character were used within the building.
This resulted in the potential for excessive fire spread (LSC 19.7.5.1).
Findings include, but are not limited to:
1. On 4/8/2015, between 10:30 a.m. and 11:30 a.m., there were shower curtains within Patient Rooms in the Family Birthing Unit that lacked documentation of being constructed or treated for fire resistance.
Patient rooms include but not limited to: Rm. 108, 109, 110, 112, 115, 120, and SANE Exam room.
2. On 4/8/2015, at 1:13 p.m., the privacy curtain within the ER Decontamination room had mesh at the top of the curtain that did not meet fire code standards.

Based on observations and interviews it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff 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 in the medical gas storage room. (LSC 19.3.2.4, NFPA 99 4.3.1.1.2).
Findings include, but are not limited to:
1. On 4/8/2015, at 1:57 p.m., there was electrical outlets and switches within 60" of the finish floor within the exterior medical compressed gas storage room of the building.

Based on record review and interviews during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1.
This resulted in the potential for injury to patients during medical procedures.
Findings include, but are not limited to:
1. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., facility documentation provided showed that humidity levels for anesthetizing locations was not being logged prior to the beginning of procedures and only being logged at the beginning of the day's first procedure.

Facility staff explained that the humidity was being monitored by an electronic system but facility was unable to provide documentation showing the monitoring of the humidity.

Based on record review and interviews during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1.
This resulted in the potential for injury to patients during medical procedures.
Findings include, but are not limited to:
1. On 4/7/2015, during record review between 11:15 a.m. and 6:00 p.m., facility documentation provided showed that humidity levels for anesthetizing locations was not being logged prior to the beginning of procedures and only being logged at the beginning of the day's first procedure.
Facility staff explained that the humidity was being monitored by an electronic system but facility was unable to provide documentation showing the monitoring of the humidity.

Based on observations and interview during the survey, it was determined through on-going dialog with the CEO, Safety Director and Engineering Services Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70.
This resulted in the potential for injury to residents & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 4/8/2015, at 8:11 a.m., there were multiple electrical conduits that were observed to be broken or cracked on the 1980 building roof for exhaust hood fans. Exhaust hood fans included but not limited to: EF3, EF4, and EF18.
2. On 4/8/2015, during the facility tour between 10:39 a.m. and 11:30 a.m., there were broken electrical outlets within the Family Birthing Center rooms. Family Birthing Center rooms included but not limited to: Rm. 108, Rm. 109, and Rm. 114.
3. On 4/8/2015, at 10:50 a.m., there were 2 patient type relocatable power taps (RPT's) that were permanently attached to the building within the Ante Nursery Rm.
4. On 4/8/2015, at 2:03 p.m., there was a power strip on the floor within the Lock Smith Office that was located behind the work bench and was exposed to metal shards created by the Key Cutting machine.
5. On 4/8/2015, at 2:03 p.m., there were electrical outlets located within the Lock Smith Office that were located behind the work bench and were exposed to metal shards created by the Key Cutting machine.

Based on observations and interview during the survey, it was determined through on-going dialog with the Safety Director and Engineering Services Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70.
This resulted in the potential for injury to residents & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 4/8/2015, at 8:40 a.m., there was a relocatable power tap (RPT) on the floor within the Med. Surge Office, Floor 3.
2. On 4/8/2015, at 8:54 a.m., there were 2-relocatable power taps (RPT's) on the floor within the Hospitalist Room, Floor 2.
3. On 4/8/2015, at 9:00 a.m., there was a power cord for the Crash Cart within the 2nd floor Nurse Work Area that was being compressed by the corner of a metal cart.
4. On 4/8/2015, at 9:14 a.m., there were multiple relocatable power taps (RPT's) on the floor within the Nurse Station Cubicles on Floor 2 and Floor 3.