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Based on observations and interview it was determined 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 19/18.1.2.3, 19/18.1.1.4, 19.1.2.3). Findings include, but are not limited to:

1. On April 16, 2012 at 3:50 p.m., there was a one-hour door in a 2-hour rated wall at the mail room in lieu of the required 90 minute rated door. The door to the mail room was also propped open with a door chock and the Maintenance Technician stated that the door was not supposed to be propped open.

2. On April 16, 2012 at 3:54 p.m., the 90-minute rated fire door across from the x-ray waiting area was dragging on the floor and not closing. The door was missing an astragal to cover the gap between the meeting edges of the two door leafs.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions.

Based on record review and interviews it was determined that the facility failed to maintain exit corridor doors to resist the passage of smoke in accordance with NFPA 80 for all corridors of the building. This resulted in the potential for the passage of smoke into the means of egress in the event of a hostile fire event (LSC 19/18.2.3.5, (Table 18.3.2.1), 19/18.3.6.3.1 Ex 2, 4.6.12.1, A19.3.6.3.3). Findings include, but are not limited to:

1. On April 16, 2012 at 4:04 p.m., during the facility record review process, the facility did not have access to the NFPA 80 1999 edition for inspecting, testing, and maintaining fire and smoke doors in the facility corridors. The facility was not keeping a monthly log of fire and smoke door inspections indicating doors that were found to need correction and the date of completion. The Maintenance Technician acknowledged that the standards were not accessible or used, as required.

2. On April 16, 2012 at 4:04 p.m., during the facility walk-thru, kick down door props were found on fire and smoke doors in the facility. These were found on the boiler room door, and LDRP room doors.

3. On April 16, 2012 at 4:47 p.m., the door closer to the equipment storage room across from room 105 was disabled and the clean utility room door by LDRP #2 had a taped latch preventing the door from latching closed.

4. On April 16, 2012 at 4:46 p.m., the soiled utility room door did not close and latch in the patient sleeping room corridor.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions.

Based on observations, interviews and record review 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 April 16, 2012, at 5:15 p.m., during the facility walk-through there was no viable emergency plan available to staff at the nurse station.

2. On April 16, 2012, at 5:15 p.m., during the facility record review process, there was no documentation of an annual review of the emergency plan, agreements, and procedures. The Code Red policy was missing from the plan. The facility did not have a proper "defend in place" policy, staff were trained to leave patients in their rooms and not to relocate to a safe smoke compartment. There was no policy regarding notification to the OSFM Health Care Unit for all fires, explosions, evacuations, and fire watches. There was no current long term evacuation site agreement with St. Charles from 2008. There was no transportation agreements in the plan. There was an outdated employee call list. The plan at the nurse station was placed in the binder upside down and backwards, making it difficult for employees to use. The plan had no index or tabs. The plan had a previous sprinkler company listed in contacts. There was no map of the facility with utility shutoff locations marked. There was no earthquake, volcano, flood, utility disruption, or hazardous material plans.

Surveyor was accompanied by the Director of Nursing and CEO who acknowledged the existence of these conditions

Based on record reviews and interviews it was determined that the facility failed to properly document 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 April 16, 2012 at 5:30 p.m., the fire drill forms that were filled out were incomplete and lacking the required information. There was no time listed for simulating the relocation of the smoke compartment. The facility was counting false alarms and actual fires as drills. The specific type of fire simulated was not indicated. The specific location of the fire was not indicated on the forms. The Maintenance Technician acknowledged that the fire drill forms did not contain the required information and stated that they were using the forms they had always used. The facility had no documentation of fire drills being conducted on the 1st and 2nd quarter 2011 second shift and 1st quarter 2012 second shift. There was no documentation of fire drills on 1st and 3rd quarter 2011 first shift.

2. On April 16, 2012 at 5:30 p.m., the facility had no documentation of inservice training for all staff within 30 days of hire and annually.

Surveyor was accompanied by the Maintenance Technician and CEO who acknowledged the existence of these conditions

3. On April 16, 2012 at 6:00 p.m., R.N. #1 was interviewed regarding responding to a fire and the disaster plan at the nurse station. She could not locate a fire alarm pull station on the unit. She stated that the patients would be evacuated to the parking lot to wait for the fire department after being coached by the Maintenance Technician. She stated that she had never heard of "defend in place" though it was in the facility plan. She struggled with the disaster plan due to it being upside down and backwards in the red notebook, she could not locate a fire procedure.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions

Based on observations and interviews it was determined 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 April 16, 2012 at 3:53 p.m., during the facility walk-through, there were horn strobes installed in patient areas throughout the facility. These devices were found in restrooms, changing rooms, dietician consult area, PT treatment room, Respiratory Therapy, PT therapy gym 207, room 212, LDRP bathrooms, birthing room, ultra sound room, radiology, recovery room and bathroom, and there was a missing audible device in the doctor sleeping room. The Maintenance Technician acknowledged that the fire alarm items were not installed as required. He indicated he was unaware of the requirement.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined that the facility failed to test and maintain fire alarm in accordance with NFPA 72 for the entire building. 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 April 16, 2012 at 4:15 p.m., during the facility walk-thru, smoke detectors in the phone/ fire alarm room were covered with tape. The Maintenance Technician acknowledged that the detectors were covered and indicated they recently installed a new phone system.

2. On April 16, 2012 at 4:39 p.m., during the facility walk-thru, there was a fire alarm pull station at the ED entrance that was obstructed with a gurney.

3. On April 16, 2012 at 5:10 p.m., during the record review process, the facility had no documentation of the required fire alarm testing for the facility in accordance with NFPA 72 other than the annual. They had no documentation of technician competence and did not have access to the adopted standards for testing and maintaining the system. The Maintenance Technician indicated that he was unaware of the requirements for technician competence, access to standards, and the requirements for fire alarm testing.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13 for all portions of the building. This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 19/18.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:

1. On April 16, 2012 at 4:15 p.m., during the facility walk-through, there was no fire sprinkler protection inside the new walk-in cooler/ freezer installed outside under the overhang. The Maintenance Technician , acknowledged that the areas were not sprinklered as required in NFPA 13 and indicated that he was unaware of the requirement.

2. On April 16, 2012 at 4:15 p.m., during the facility walk-thru, the fire department connection was relocated and was not provided with a sign stating "FDC" in 6" block letters red on white background. The FDC was missing caps to prevent obstructions to the sprinkler system. The facility had no documentation of a backflush of the new FDC to verify no obstructions.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined 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 April 16, 2012 at 4:01 p.m., during the facility walk-through, there were corroded sprinkler heads at the dishwashing area and a missing escutcheon plate in the conference room 111. The gauges on the sprinkler riser were dated 2000 and were past due for 5 year calibration/ replacement. The Maintenance Technician acknowledged that there was corrosion on the heads.

2. On April 16, 2012 at 5:15 p.m., 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. The Maintenance Technician, acknowledged that the forward flow test results were not available for review, and indicated that Alpine Fire Protection did not conduct the test during the 4/29/11 annual inspection.

3. On April 16, 2012 at 5:30 p.m., during the record review process, the facility had no documentation of the required sprinkler testing for the facility in accordance with NFPA 25 other than the annual. They had no documentation of technician competence and did not have access to the adopted standards for testing and maintaining the system. The Maintenance Technician indicated that he was unaware of the requirements for technician competence, access to standards, and the requirements for fire sprinkler testing.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions.

Based on record review, observations and interview it was determined that the facility failed to maintain fire extinguishers in accordance with adopted standards for the facility. This resulted in the potential for fires to progress beyond incipient stage (LSC 19/18.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:

1. On April 16, 2012 at 5:15 p.m., during the record review process the facility had no access to the adopted standards (NFPA 10 1998 edition) for inspecting, testing, and maintaining fire extinguishers.

2. On April 16, 2012 at 4:15 p.m., during the facility walk-through, there was a "K" class fire extinguisher in the kitchen and the facility did not have a fryer, there was no class ABC fire extinguisher in the kitchen. The CEO, indicated that they previously had a fryer in the kitchen.

3. On April 16, 2012 at 4:39 p.m., there was a fire extinguisher in the ED entrance that was obstructed by a gurney, and a fire extinguisher at room 105 that was obstructed by a wheel chair.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions.

Based on observation and interview it was determined that the facility failed to install a Type 2 ventilation hood and duct system in the kitchen for the dishwasher. This resulted in the potential for structural damage and corrosion to the sprinkler system due to inappropriate and/or inadequate steam removal. Findings include, but are not limited to:

1. On 4/16/2012 at 4:01 p.m., during the facility walk-thru there was no Type 2 hood installed at the dishwasher to remove heat and steam from the kitchen. The Maintenance Technician acknowledged that there was no hood and that the sprinkler heads were corroded.

2. On 4/16/2012 at 3:57 p.m., during the facility walk-thru, the Ansul pull station in the kitchen was obstructed by a cart and was installed more than 48" above the floor to the center of the pull station.

3. On 4/16/2012 at 3:58 p.m., during the facility walk-thru, the kitchen hood filters were greasy and dirty. Kitchen staff indicated that the filters were not cleaned daily.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions.

Based on observations and interview it was determined that the facility failed to prohibit the use of portable space heating devices. This resulted in the potential for ignition of nearby combustibles (LSC 19/18.7.8). Findings include, but are not limited to:

1. On 4/16/2012 at 4:01 p.m., during the facility walk-thru there were space heaters in use in the Chemo-therapy room 234R and in the doctor's sleeping room.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions.

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 April 16, 2012 at 4:45 p.m., during the facility walk-through, there were unattended linen carts, computer on wheels, wheel chairs, walkers, library cart, coffee maker and toaster, bath chair, x-ray equipment, boxes, recycle bins, and other items. The Maintenance Technician acknowledged that the items were not removed from the corridor within 30 minutes or when staff went on break as required. He indicated that he believed the items were allowed if kept on one side of the corridor.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to ensure that no storage of highly flammable character existed in the corridors for 1 of 4 sampled corridors of the building. This resulted in the potential for excessive fire spread (LSC 19/18.7.5.5, Exhibit 19/18.23). Findings include, but are not limited to:

1. On April 16, 2012 at 4:53 p.m., during the facility walk-through, there was a recycle bin and a soiled linen cart in areas open to the corridor in lieu of storage in a 1 hour rated room. The Maintenance Technician indicated that he was unaware of the requirement.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to provide safe storage for compressed gas (for light switch in oxygen storage room/ref. NFPA 99, A-4-3.1.1.2(a)2 #4). This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks (LSC 19/18.3.2.4, 4.3.1.1.2). Findings include, but are not limited to:

1. On April 16, 2012 at 6:05 p.m., during the facility walk-thru, the med gas cylinder had only one chain securing them from tipping. The Maintenance Technician stated he was unaware of the requirement for two chains.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions.

Based on record review and interviews it was determined that the facility failed to ensure that piped in medical gas systems comply with NFPA 99. This resulted in the potential for injury to patients during medical procedures. Findings include but are not limited to:

1. On April 16, 2012 at 4:44 p.m., during the record review process, the facility had no documentation of an annual med gas certification. The Maintenance Technician indicated he was unaware of the requirement for annual med gas certifications.

2. On April 16, 2012 at 4:28 p.m., the med gas shutoff valves throughout the hospital were not labeled appropriately. The labels did not indicate the correct rooms that the valves served.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions.

Based on observations and interview it was determined that the facility failed to maintain the generator room free of storage. This resulted in the potential for unexpected ignition source & excessive fire spread. Findings include, but are not limited to:

1. On April 16, 2012 at 3:45 p.m., during the facility walk-thru there was flammable and combustible storage in the Generator room. The facility had cut a hole in the wall between the generator room and the adjacent storage room to provide better air flow, per the CEO.

Based on observations and interview it was determined that the facility failed to maintain dryers (NFPA 54). This resulted in the potential for unexpected ignition source & excessive fire spread. Findings include, but are not limited to:

2. On April 16, 2012 at 5:15 p.m., there was excessive lint in the top rear of the laundry dryers at the burner box. The dryer exhaust duct was improperly taped with non-listed tape.

Surveyor was accompanied by the Maintenance Technician and CEO, who acknowledged the existence of the above conditions.

Based on record review and interviews it was determined 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 April 16, 2012 at 4:05 p.m., during the record review process, the facility had no documentation of the required generator testing for the facility in accordance with NFPA 110 other than the annual. They had no documentation of technician competence and did not have access to the adopted standards for testing and maintaining the system.

2. On April 16, 2012 at 5:30 p.m., the facility had no documentation of ever conducting the required 3 year 4 hour 80% load bank test of the generator or the weekly electrolyte level testing.

On April 16, 2012 at 5:30 p.m., the Maintenance Technician indicated that he was unaware of the requirements for technician competence, access to standards, and the requirements for generator testing.

3. On April 16, 2012 at 4:09 p.m., there were no battery powered emergency lights installed at the generator and transfer switches for troubleshooting the generator.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions.

Based on observations and interview it was determined that the facility failed to provide an alternate source of power in accordance with NFPA 99 3.6. that would provide a minimum of 90 minutes of power in an outage. This resulted in the potential for panic and confusion for staff and residents in a power outage. Findings include, but are not limited to:

1. On April 16, 2012 at 5:09 p.m., there were no battery powered emergency lights in procedure and operating rooms.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of the above conditions.

Based on observations and interviews it was determined that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for the building. This resulted in the potential for injury to residents & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:

1. On April 16, 2012 at 4:15 p.m., during the facility walk-through, there were relocatable power taps in the telephone/ fire alarm room, in the dietician consult room, in Respiratory Therapy, charting station across from PT Therapy, in the PT Therapy office and gym, in the Doctor's lounge, in the LDRP storage room, in the Ultrasound room, in the X-Ray office, in room 285, room 210, room 212, across from room 268, in Minor Surgery suite 279 that were the improper type or were improperly used.

2. On April 16, 2012 at 4:15 p.m., during the facility walk-through, there was a refrigerator plugged into a power tap and not directly into the wall in the Doctor's Lounge, an extension cord to the TV in the ED waiting room, extension cords daisy chained to a power strip in room 285, a household use only microwave in room 210, a refrigerator plugged into a power strip in room 210, a yellow extension cord to the phone system at the nurse station adjacent to the microwave, an extension cord to heat tape in the med gas room.

3. On April 16, 2012 at 5:30 p.m., there was an electrical light switch in the med gas storage room installed within 60" of the floor.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions.

Based on observations and interviews it was determined that the facility failed to install alcohol gel hand sanitizing dispensing stations away from sources of ignition for 1 resident room of the building. This resulted in the potential for injury to residents and staff (LSC 18.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623). Findings include, but are not limited to:

1. On April 16, 2012 at 4:49 p.m., during the facility walk-through, there was an alcohol hand gel dispenser installed above a light switch in room 105, 271, and OR #1. The Maintenance Technician, acknowledged that the hand gel dispenser was not installed a minimum of 1" to the side of the light switch as required.

Surveyor was accompanied by the Maintenance Technician who acknowledged the existence of these conditions.