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Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations 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 6/10/2015, at 3:35 p.m., there were unsealed wall penetrations within the 2-hr. rated corridor wall at the MRI Equipment Room that measure approximately 1" and 4" in diameter.
2. On 6/10/2015, at 4:02 p.m., there was missing fire insulation proofing on the structural steel within the Recycle Rm. within the Covered Parking Garage.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations 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 patients & staff to hazardous products of fire (LSC 18.3.6.1, .2, .5).
Findings include, but are not limited to:
1. On 6/10/2015, at 9:00 a.m., there were unsealed penetrations within the 2-hr. wall around flexible conduit above the door inside the Cardiopulmonary Services area.
2. On 6/10/2016, during the facility tour between 9:00 a.m. and 4:30 p.m., there was exposed combustible construction within the Kitchen and Video Conference Storage Closet of the East Building (Old Hospital).
3. On 6/10/2015, at 3:40 p.m., there was a double-leaf fire door that was not closing or latching properly on floor #2 adjacent to the main Elevator Lobby.
4. On 6/10/2015, during the facility tour between 9:00 a.m. and 4:30 p.m., the doors within the 1-hr. separation on the first floor near the vending machines and at the kitchen within the atrium of the Main Hospital Building failed to latch and close properly.
5. On 6/10/2015, at 4:22 p.m., there was a single door within the 2-hr. separation adjacent to the HR Office that was not closing or latching properly.
6. On 6/10/2015, at 4:53 p.m., there was an unsealed wall penetration in the 1-hr. wall above the double-doors adjacent to the Board Rm. that measured approximately 1" in diameter.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to maintain the integrity of Class A or Class B interior finish for corridors and exitways, including exposed interior surfaces of buildings.
This resulted in the potential for uncontrolled heat, flame and smoke migration into the concealed spaces and corridors in the event of a fire, causing the exposure of patients & staff to hazardous products of fire (LSC 19.3.3.1, 19.3.3.2).
Findings include, but are not limited to:
1. On 6/10/2015, at 3:02 p.m., there were missing ceiling tiles in the southeast hallway of the East Building (Old Hospital).
2. On 6/10/2015, at 3:29 p.m., there were multiple ceiling penetrations within the East Building OB area (Old Hospital) that would allow products of combustion into the attic space and concealed spaces within the hospital.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to install vertical openings that are capable of resisting the passage of fire and provide basic smoke compartmentation.
This resulted in the potential for the spread of fire and smoke vertically in multi-story facilities. (LSC 18.3.1.1, 8.2.5.1).
Findings include, but are not limited to:
1. On 6/10/2015, at 2:58 p.m., the smoke and fire door that protects the east elevator vertical shaft within the Emergency Department was not closing or latching properly when tested by the surveyor.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to maintain approved smoke barrier doors of the building.
This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 18.2.3.5, 18.3.6.3, 4.6.12.1).
Findings include, but are not limited to:
1. On 6/9/2015, during record review between 1:30 p.m. to 5:30 p.m., there was no documentation provided by the facility showing smoke and fire door maintenance and testing for the doors within the facility.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to provide a one hour separation between hazardous areas and the corridor for the building.
This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 18.3.2, 8.4).
Findings include, but are not limited to:
1. On 6/10/2015, at 2:26 p.m., there was an unapproved hold open device (cardboard wedge) on the Soiled Processing door within the Surgical Suite area.
2. On 6/10/2015, at 2:27 p.m., there was a missing door closure on the Biohazard Room door within the Surgical Suite area.
3. On 6/10/2015, at 2:45 p.m., the Soiled Utility room door outside of the Surgical Hallway was not closing or latching properly.
4. On 6/10/2015, at 3:20 p.m., the Soiled Linen room door across from Patient Rm. 303 was not closing or latching properly.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to provide a one hour separation between hazardous areas and the main portion of the building.
This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 38.3.2, 8.4).
Findings include, but are not limited to:
1. On 6/11/2015, at 8:48 a.m., there was a missing door closure on the stairwell door from the first floor to the second floor storage room area.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to maintain accessible exits for the building as required (LSC 20.2.3, 20.3.7.6, 38.2.2, 7.7).

This resulted in the potential for panic and injury to occupants.

Findings include, but are not limited

1. On 6/11/2015, at 9:00 a.m., the exit light above an exit door on the north side of the building adjacent to Rm. 26 did not work when tested by the surveyor.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to maintain exit illumination on emergency power for a minimum of 90 minutes annually for the building.
This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions (LSC 18/19.2.8).
Findings include, but are not limited to:
1. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., the facility failed to provide documentation of monthly and annual required testing of emergency egress lighting for the Main Hospital and East Building (old hospital).
2. On 6/10/2015, at 2:24 p.m., there was an emergency battery powered light within Procedure Room #1 that was not working when tested by the surveyor.
3. On 6/10/2015, during the facility tour between 3:00 p.m. and 4:00 p.m., the East Building (Old Hospital) emergency egress lighting fixtures failed to illuminate when the test button was depressed by the surveyor.
This deficiency was noted in the following areas but not limited to: Southeast Hallway, Environmental Services Hallway, outside ER Entrance, and Sterile Care area.

Based on record review and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to maintain exit illumination on emergency power for a minimum of 90 minutes annually.
This resulted in the potential for confusion and panic by patients & staff during emergency evacuation conditions (LSC 38.2.8, 38.2.9).
Findings include, but are not limited to:
1. On 6/10/2015, during record review between 9:00 a.m. and 9:30 a.m., there was no documentation showing the required monthly 30 second test or annual 90 minute test on emergency lights within the facility.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Plant Operations 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 20.7.1.1).
Findings include, but are not limited to:
1. On 6/11/2015, during record review between 9:00 a.m. and 9:30 a.m., the disaster plan provided by the facility to the surveyor did not have an annual review date.
2. On 6/11/2015, during record review between 9:00 a.m. and 9:30 a.m., the disaster plan provided by the facility to the surveyor did not have a facility map showing the physical location of utility shutoffs (electric, gas, water, etc.) in the event the utilities needed to be shut down during/after an emergency event.
3. On 6/11/2015, during record review between 9:00 a.m. and 9:30 a.m., the facility did not have current transfer agreements, and current transportation agreements with equivalent facilities.

Based on interviews, record review and observations during the survey, it was determined through on-going dialog with the Plant Operations 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 6/10/2015, during record review between 8:00 a.m. and 10:30 a.m., the facility failed to maintain a current call list in the disaster plan, the date on the list in the plan provided for review was dated 6/11/2011.
2. On 6/10/2015, at 2:37 p.m., the Facilities Emergency Disaster Plan at the nurses station within the Surgical Suite had a review date of August 2011 and was past due for annual review since August 2012.
According to documentation provided by the facility, the new hospital obtained their Certificate of Occupancy on April 2012 and the Emergency Disaster Plan that was kept at the Nurse station within the Surgical Suite was for the previous Surgical area for the old hospital.
3. On 6/10/2015, at 3:16 p.m., the Facilities Emergency Disaster Plan at the nurses station within the Med. Surgical area had a review date of August 2011 and was past due for annual review since August 2012.
According to documentation provided by the facility, the new hospital obtained their Certificate of Occupancy on April 2012 and the Emergency Disaster Plan that was kept at the Nurse station within the Med. Surgical area was for the previous Med. Surgical area for the old hospital.
4. On 6/10/2015, at 3:16 p.m., the Facilities Emergency Disaster Plan at the nurses station within the Emergency Dept. had a review date of August 2011 and was past due for annual review since August 2012.
According to documentation provided by the facility, the new hospital obtained their Certificate of Occupancy on April 2012 and the Emergency Disaster Plan that was kept at the Nurse station within the Emergency Dept. was for the previous Emergency Dept. for the old hospital.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Plant Operations 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 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., the facility had no documentation on conducting 1st and 2nd quarter day shift fire drills for 2014 and 1st and 2nd quarter night shift fire drills for 2014. The facility had no documentation on conducting their 1st quarter night shift fire drill for 2015.
2. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility.
Fire drill forms were missing items such but not limited to: number of simulated patients evacuated from the affected smoke compartment to a unaffected smoke compartment, time to complete simulated evacuation of patients, specific type of fire simulated, specific location of simulated fire type, and staff performance.
3. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., fire drill documentation presented to the surveyor's by the facility showed that an actual event was used as a fire drill for the facilities 2nd quarter day shift drill.
4. On 6/10/2015, at 10:57 a.m., surveyor's conducted a fire drill on the 3rd floor of the facility. During the drill, the surveyor noted the following problems/deficiencies: Staff were complacent, the fire alarm was silenced during the drill, there was no clear leadership during the drill, corridors within the affected smoke compartment were not cleared, corridors within the adjacent smoke compartment were not cleared and made ready to accept incoming patients, no simulated patient removal from the affected smoke compartment to a unaffected smoke compartment, and some staff did not know the location of the fire alarm pull stations within the unit they worked within.
The Fire Response Plan policy directs staff at Coquille Valley Hospital to always relocate horizontally first in fire situations, then vertically if required. During the drill conducted at 10:57 a.m., there was no relocation of patients horizontally or vertically as mentioned in the policy and staff within the unit were the fire drill was held mentioned that they have never been trained to relocate patients.
5. On 6/10/2015, at 8:10 p.m., surveyor's conducted a fire drill on the 3rd floor of the facility. During the drill, the surveyor noted the following problems/deficiencies: Staff were complacent, staff member did not know how to conduct an overhead page, the fire alarm pull stations was not initiated by 3 staff members that walked by the pull station, corridors within the affected smoke compartment were not cleared, smoke and fire doors were closed manually because the fire alarm was not immediately initiated.
The fire extinguisher was brought to the nurse station and not fire room, staff member did not know were the fire room was, the fire alarm was silenced, no clear leadership, code red announcement was completed but very faint and only repeated once, and there was no simulated patient removal from the affected smoke compartment to an unaffected smoke compartment. Staff mentioned "if we were told to evacuate patients, we would start doing that evacuation".

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff 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 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., there were no required yearly, quarterly, and monthly fire alarm inspection/maintenance reports for the Clinic Building adjacent to the Main Hospital.
2. On 6/11/2015, at 9:06 a.m., there was a missing mechanical set screw lock on the electrical breaker for the Fire Alarm Control Panel.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff 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 6/9/8/2015, during record review between 1:30 p.m. and 5:30 p.m., monthly testing and maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the fire alarm system to the adopted 1999 edition of NFPA 72 standards.
2. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., facility staff failed to maintain documentation of monthly and quarterly fire alarm testing and maintenance.
3. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., the facility failed to provide proper and complete documentation of the annual fire alarm system testing and maintenance in accordance with NFPA 72, 1999 edition, 7-5.2 standards.
4. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., there were no required annual, quarterly, and monthly inspection/maintenance reports for the Old Hospital Building.
5. On 6/10/2015, at 2:40 p.m., there was an obstructed/blocked fire alarm pull station by a cart at the Med. Surge Nurse Station.
6. On 6/10/2015, at 2:50 p.m., there was coban material taped to the fire alarm notification device within the Physician On-Call Sleep Room.
7. On 6/10/2015, at 2:53 p.m., there was a protective cover in place covering one of the fire alarm detectors within the East Building Maintenance shop.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13 for the building.
This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 18.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25).
Findings include, but are not limited to:
1. On 6/9/2015, at 3:25 p.m., there was missing automatic sprinkler protection for the exterior awning constructed of wood between the new hospital building on the old hospital building.
Plant Operations Staff mentioned to surveyors that the exterior awning was constructed with non-combustible or limited combustible wood. Plant Operations Staff could not provide any information or documentation to support the construction type of the exterior awning.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition for the 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 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., weekly and monthly testing and maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the sprinklers to the adopted 1998 edition of NFPA 25 standards.
2. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., required weekly and monthly testing and maintenance for the facilities automatic sprinkler system was not being documented/performed for the New Hospital Building and East Building (Old Building).
3. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., there was no required documentation for testing and maintenance for the smoke and fire dampers for the facility.
4. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., there was no required documentation for maintenance and testing of the smoke and fire dampers within the facility.
5. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., the facility failed to provide documentation that the water going for the fire protection system in the East Building had been repaired. Quarterly testing report (1/13/2015) and annual report (4/6/2015) indicated that the device was not functioning.
6. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., the facility failed to provide documentation that the plugged anti-freeze line for the fire protection sprinkler system in the East Building (Old Hospital) had been flushed and the system re-filled to provided adequate freeze protection. Annual testing report (4/6/2015) indicated the deficiency.
7. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., the facility failed to provide documentation that painted fire protection sprinkler heads in the East Building (Old Building) had been replaced. This deficiency was noted on the last two annual inspection reports (4/6/2015 and 4/28/2014).
8. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., the facility failed to document monthly and annual fire pump testing and maintenance.
9. On 6/10/2015, at 3:48 p.m., there were corroded automatic sprinkler heads that need to be replaced within the covered parking garage area.
10. On 6/10/2015, at 3:49 p.m., there was a damaged automatic sprinkler head that needs to be replaced within the covered parking garage area near the entrance to the parking area.
11. On 6/10/2015, at 4:06 p.m., there was a corroded automatic sprinkler head within the walk-in freezer in the kitchen that needs to be replaced.
12. On 6/10/2015, at 4:20 p.m., the pre-action sprinkler system for the IT Room had an electrical switch for the compressor that was hooked to the system that did not have a lock out on the switch. Switch was located within the Electrical Environmental Services room within the Administration Corridor.
13. On 6/10/2015, at 4:28 p.m., there was a missing sidewall sprinkler head within the spare sprinkler cabinet. Facility is required to have a minimum of 12 spare sprinkler heads or 2 of each type and temperature, which ever is greater for facilities having between 300 and 1000 sprinkler heads within the system.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Plant Operations 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 3-3, 8-4.6, 9-1).
Findings include, but are not limited to:
1. On 6/10/2015, during record review between 1:30 p.m. and 5:30 p.m., the facility failed to provide documentation of weekly and monthly maintenance and inspections on the fire protection sprinkler system for the Clinic Building adjacent to the Main Building.
2. On 6/11/2015, at 9:12 a.m., there was a missing replacement dry-sidewall sprinkler head for the buildings automatic sprinkler system.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff 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 18.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10).
Findings include, but are not limited to:
1. On 6/9/2015, at 3:40 p.m., there was only a Purple "K" fire extinguisher at the Helipad of the facility and not the required 10A 120B rated fire extinguisher for aircraft 50' - 80' in length.
2. On 6/10/2015, at 4:07 p.m., there was a missing Type K fire extinguisher for the UL 300 listed Kitchen Hood within the main Kitchen. This deficiency was noted on the Kitchen Hood Fire Protection System Report from 9/10/2012.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to prohibit the use of portable space heating devices.
This resulted in the potential for ignition of nearby combustibles (LSC 18.7.8).
Findings include, but are not limited to:
1. On 6/10/2015, at 2:48 p.m., there was a space heater that was not in use behind the door within the Nurse Breakroom adjacent to the Emergency Department.
2. On 6/10/2015, at 3:53 p.m., there was a space heater within the Video Conference Rm. of the East Building (Old Hospital) which was in the patient wing.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections for 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 6/10/2015, at 2:45 p.m., there were obstructions within the constructed clear width exit egress Surgical Hallway corridor consisting of two storage carts.
2. On 6/10/2015, at 2:48 p.m., there were obstructions within the constructed clear width exit egress corridor within the Emergency Department consisting of electrical BP machines that were plugged into electrical outlets.
3. On 6/10/2015, at 3:03 p.m., there were obstructions within the constructed clear width exit egress corridor outside of Patient Rm. 310 consisting of an easel and computer cart.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to provide safe storage for compressed gas in the facility.
This resulted in the potential for injury to staff and patients from a damaged compressed gas cylinder releasing unexpectedly. (LSC 38.3.2, NFPA 99 4.3.1.1.2).
Findings include, but are not limited to:
1. On 6/11/2015, at 8:55 a.m., there was a compressed gas cylinder that was not properly secured by evidence of only a single chain at the top of the cylinder that would allow the bottoms of the cylinder to kick out and strike other cylinders or walls within Procedure Rm #1 during a seismic event.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Plant Operations 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. (LSC 18.3.2.4, NFPA 99 4.3.1.1.2).
Findings include, but are not limited to:
1. On 6/10/2015, at 2:30 p.m., there were multiple compressed gas cylinders being stored within an alcove within the Surgical Suite Recover area that had electrical outlets within 60" of the finish floor.
Based on observations and interviews during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to provide safe storage for compressed gas in the facility.
This resulted in the potential for injury to staff and patients from a damaged compressed gas cylinder releasing unexpectedly. (LSC 18.3.2.4, NFPA 99 4.3.1.1.2). Findings include, but are not limited to:
2. On 6/10/2015, at 3:40 p.m., there were compressed gas cylinders that were not properly secured by evidence of the cylinders standing in a free non-restrained fashion that would allow the cylinders to fall and strike other cylinders or walls within the East Building Doctor's Office adjacent to the door going into the office.

Based on record review and interview during the survey, it was determined through on-going dialog with the Plant Operations 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 6/9/2015, during record review between at 1:30 p.m. to 5:30 p.m., the humidity policy (Maintaining a Safe, Functional Environment, EC.02.06.01) dated 5/2012 that was presented to the surveyor provide a humidity range of 35% - 60%.
Facility personnel could not provide humidity logs prior to January 2014 because the humidity was being monitored by a computer system. Humidity logs that were presented and reviewed showed the following days that the humidity was measured out of adopted range: OR #1 on 12/30-31/2014, 1/21/2015 and 5/11/2015.
Policy EC.02.06.01 states that "temperature and humidity conditions shall be monitored and recorded daily in anesthetizing locations" and "each anesthetizing location shall be equipped with a reliable measuring devices capable of displaying present temperature and humidity conditions.
Measuring devices shall be calibrated or replaced annually". Facility could not provide any documentation on the recalibration of replacement of the temperature and humidity devices used within the facility. Policy EC.02.06.01 states, "In the event of an unsatisfactory test result or discovery or a system that is not functioning properly, the infection control department and the affected area(s) or department(s) will be notified immediately, an appropriate corrective action plan shall be documented, follow-up testing and inspections shall be performed and documented prior to re-commissioning the space".
Facility could not provide any documentation on the day's the humidity was measured out of the adopted range.

Based on observations, record review and interviews it was determined through on-going dialog with the Plant Operations Staff that the facility failed to properly maintain the generator affecting the entire facility.
This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2).
Findings include, but are not limited to:
1. On 6/9/2015, during record review, between 1:30 p.m. and 5:30 p.m., monthly maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the generator the adopted 1999 edition of NFPA 110 standards.
2. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., the required 3-year, 4-hour load bank test was completed on 4/8/2015, was not completed to the requirements within NFPA 110. The load bank test was not at a minimum of 4-hours at 80% of the nameplate of the generator.
3. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., there was no weekly electrolyte testing and monthly specific gravity testing for the 125 kW generator.
4. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., there was no documentation of the required monthly specific gravity checks for February 2015, January 2015, December 2014, November 2014, September 2014, July 2014, June 2014, March 2014 and January 2014.
5. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., there was no documentation of the required weekly water or electrolyte checks for both generators for the year 2012 and 2013.
6. On 6/9/2015, at 3:20 p.m., there was no emergency generator stop button installed outside of the generator enclosure.
7. On 6/9/2015, at 3:20 p.m., there was no required battery powered task illumination at the 300 kW generator.
8. On 6/9/2015, at 3:30 p.m., there were maintenance free batteries installed on the 125 kW generator for the old building.

Based on record review and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to provide an alternate source of power in accordance with NFPA 99 3.6, which 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 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., there was no documentation showing the required monthly 30 second test or annual 90 minute test on emergency lights within the generator enclosure or generator transfer switch.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff 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 patients & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 6/10/2015, at 2:38 p.m., there was a relocatable power tap on the floor within the Anesthesia Office.
2. On 6/10/2015, at 2:50 p.m., there was a household grade microwave within the Physician's On-Call Sleep Room.
3. On 6/10/2015, at 2:57 p.m., there was a relocatable power tap (RPT) on the wall behind the bench grinder within the East Building Maintenance Shop that was exposed to metal fillings and metal shards as evidence of the fillings and shards found within the outlets of the RPT.
4. On 6/10/2015, during the facility tour between 3:00 p.m. and 4:00 p.m., there was exposed energized electrical wiring within the East Building (Old Hospital) noted in the following locations but not limited to: Women's OR Dressing Room, OR area, OB area, Lab and Kitchen.
5. On 6/10/2015, at 3:42 p.m., there were two household hotplate devices within a servery room adjacent to the Conference/Board Room.
6. On 6/10/2015, at 3:42 p.m., there was a relocatable power tap (RPT) within the Nurse's Office in the East Building (Old Hospital) that was not equipped with overcurrent protection.
7. On 6/10/2015, at 3:45 p.m., there was an extension cord in use powering a light within the Maintenance Office.
8. On 6/10/2015, at 3:45 p.m., there was a relocatable power tap (RPT) on the floor within the Maintenance Office.
9. On 6/10/2015, at 3:55 p.m., there Fire Alarm Control Panel breaker within panel LSL2 was painted and needs to be replaced.
10. On 6/10/2015, at 4:20 p.m., there were multiple relocatable power taps (RPT's) on the floor within Administration and IT areas.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff 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 patients & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 6/11/2015, at 8:45 a.m., there was an open electrical junction box on the 2nd floor/storage floor near the SE corner of the building.
2. On 6/11/2015, at 8:58 p.m., there was a 6:2 cube adapter plugged into an electrical outlet within the Exam/PR room (Rm. #20).
3. On 6/11/2015, at 9:04 p.m., the electrical breaker for the Fire Alarm Control Panel was painted and needs to be replaced.

Based on the observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to install alcohol based hand rub (ABHR) dispensers away from sources of ignition for the building.
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 6/10/2012, at 2:16 p.m., there was an alcohol based hand rub dispenser that was installed above an electrical outlet within OR #1 and OR #2.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations 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 6/10/2015, at 3:35 p.m., there were unsealed wall penetrations within the 2-hr. rated corridor wall at the MRI Equipment Room that measure approximately 1" and 4" in diameter.
2. On 6/10/2015, at 4:02 p.m., there was missing fire insulation proofing on the structural steel within the Recycle Rm. within the Covered Parking Garage.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations 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 patients & staff to hazardous products of fire (LSC 18.3.6.1, .2, .5).
Findings include, but are not limited to:
1. On 6/10/2015, at 9:00 a.m., there were unsealed penetrations within the 2-hr. wall around flexible conduit above the door inside the Cardiopulmonary Services area.
2. On 6/10/2016, during the facility tour between 9:00 a.m. and 4:30 p.m., there was exposed combustible construction within the Kitchen and Video Conference Storage Closet of the East Building (Old Hospital).
3. On 6/10/2015, at 3:40 p.m., there was a double-leaf fire door that was not closing or latching properly on floor #2 adjacent to the main Elevator Lobby.
4. On 6/10/2015, during the facility tour between 9:00 a.m. and 4:30 p.m., the doors within the 1-hr. separation on the first floor near the vending machines and at the kitchen within the atrium of the Main Hospital Building failed to latch and close properly.
5. On 6/10/2015, at 4:22 p.m., there was a single door within the 2-hr. separation adjacent to the HR Office that was not closing or latching properly.
6. On 6/10/2015, at 4:53 p.m., there was an unsealed wall penetration in the 1-hr. wall above the double-doors adjacent to the Board Rm. that measured approximately 1" in diameter.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to maintain the integrity of Class A or Class B interior finish for corridors and exitways, including exposed interior surfaces of buildings.
This resulted in the potential for uncontrolled heat, flame and smoke migration into the concealed spaces and corridors in the event of a fire, causing the exposure of patients & staff to hazardous products of fire (LSC 19.3.3.1, 19.3.3.2).
Findings include, but are not limited to:
1. On 6/10/2015, at 3:02 p.m., there were missing ceiling tiles in the southeast hallway of the East Building (Old Hospital).
2. On 6/10/2015, at 3:29 p.m., there were multiple ceiling penetrations within the East Building OB area (Old Hospital) that would allow products of combustion into the attic space and concealed spaces within the hospital.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to install vertical openings that are capable of resisting the passage of fire and provide basic smoke compartmentation.
This resulted in the potential for the spread of fire and smoke vertically in multi-story facilities. (LSC 18.3.1.1, 8.2.5.1).
Findings include, but are not limited to:
1. On 6/10/2015, at 2:58 p.m., the smoke and fire door that protects the east elevator vertical shaft within the Emergency Department was not closing or latching properly when tested by the surveyor.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to maintain approved smoke barrier doors of the building.
This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 18.2.3.5, 18.3.6.3, 4.6.12.1).
Findings include, but are not limited to:
1. On 6/9/2015, during record review between 1:30 p.m. to 5:30 p.m., there was no documentation provided by the facility showing smoke and fire door maintenance and testing for the doors within the facility.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to provide a one hour separation between hazardous areas and the corridor for the building.
This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 18.3.2, 8.4).
Findings include, but are not limited to:
1. On 6/10/2015, at 2:26 p.m., there was an unapproved hold open device (cardboard wedge) on the Soiled Processing door within the Surgical Suite area.
2. On 6/10/2015, at 2:27 p.m., there was a missing door closure on the Biohazard Room door within the Surgical Suite area.
3. On 6/10/2015, at 2:45 p.m., the Soiled Utility room door outside of the Surgical Hallway was not closing or latching properly.
4. On 6/10/2015, at 3:20 p.m., the Soiled Linen room door across from Patient Rm. 303 was not closing or latching properly.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to provide a one hour separation between hazardous areas and the main portion of the building.
This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 38.3.2, 8.4).
Findings include, but are not limited to:
1. On 6/11/2015, at 8:48 a.m., there was a missing door closure on the stairwell door from the first floor to the second floor storage room area.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to maintain accessible exits for the building as required (LSC 20.2.3, 20.3.7.6, 38.2.2, 7.7).

This resulted in the potential for panic and injury to occupants.

Findings include, but are not limited

1. On 6/11/2015, at 9:00 a.m., the exit light above an exit door on the north side of the building adjacent to Rm. 26 did not work when tested by the surveyor.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to maintain exit illumination on emergency power for a minimum of 90 minutes annually for the building.
This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions (LSC 18/19.2.8).
Findings include, but are not limited to:
1. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., the facility failed to provide documentation of monthly and annual required testing of emergency egress lighting for the Main Hospital and East Building (old hospital).
2. On 6/10/2015, at 2:24 p.m., there was an emergency battery powered light within Procedure Room #1 that was not working when tested by the surveyor.
3. On 6/10/2015, during the facility tour between 3:00 p.m. and 4:00 p.m., the East Building (Old Hospital) emergency egress lighting fixtures failed to illuminate when the test button was depressed by the surveyor.
This deficiency was noted in the following areas but not limited to: Southeast Hallway, Environmental Services Hallway, outside ER Entrance, and Sterile Care area.

Based on record review and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to maintain exit illumination on emergency power for a minimum of 90 minutes annually.
This resulted in the potential for confusion and panic by patients & staff during emergency evacuation conditions (LSC 38.2.8, 38.2.9).
Findings include, but are not limited to:
1. On 6/10/2015, during record review between 9:00 a.m. and 9:30 a.m., there was no documentation showing the required monthly 30 second test or annual 90 minute test on emergency lights within the facility.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Plant Operations 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 20.7.1.1).
Findings include, but are not limited to:
1. On 6/11/2015, during record review between 9:00 a.m. and 9:30 a.m., the disaster plan provided by the facility to the surveyor did not have an annual review date.
2. On 6/11/2015, during record review between 9:00 a.m. and 9:30 a.m., the disaster plan provided by the facility to the surveyor did not have a facility map showing the physical location of utility shutoffs (electric, gas, water, etc.) in the event the utilities needed to be shut down during/after an emergency event.
3. On 6/11/2015, during record review between 9:00 a.m. and 9:30 a.m., the facility did not have current transfer agreements, and current transportation agreements with equivalent facilities.

Based on interviews, record review and observations during the survey, it was determined through on-going dialog with the Plant Operations 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 6/10/2015, during record review between 8:00 a.m. and 10:30 a.m., the facility failed to maintain a current call list in the disaster plan, the date on the list in the plan provided for review was dated 6/11/2011.
2. On 6/10/2015, at 2:37 p.m., the Facilities Emergency Disaster Plan at the nurses station within the Surgical Suite had a review date of August 2011 and was past due for annual review since August 2012.
According to documentation provided by the facility, the new hospital obtained their Certificate of Occupancy on April 2012 and the Emergency Disaster Plan that was kept at the Nurse station within the Surgical Suite was for the previous Surgical area for the old hospital.
3. On 6/10/2015, at 3:16 p.m., the Facilities Emergency Disaster Plan at the nurses station within the Med. Surgical area had a review date of August 2011 and was past due for annual review since August 2012.
According to documentation provided by the facility, the new hospital obtained their Certificate of Occupancy on April 2012 and the Emergency Disaster Plan that was kept at the Nurse station within the Med. Surgical area was for the previous Med. Surgical area for the old hospital.
4. On 6/10/2015, at 3:16 p.m., the Facilities Emergency Disaster Plan at the nurses station within the Emergency Dept. had a review date of August 2011 and was past due for annual review since August 2012.
According to documentation provided by the facility, the new hospital obtained their Certificate of Occupancy on April 2012 and the Emergency Disaster Plan that was kept at the Nurse station within the Emergency Dept. was for the previous Emergency Dept. for the old hospital.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Plant Operations 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 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., the facility had no documentation on conducting 1st and 2nd quarter day shift fire drills for 2014 and 1st and 2nd quarter night shift fire drills for 2014. The facility had no documentation on conducting their 1st quarter night shift fire drill for 2015.
2. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility.
Fire drill forms were missing items such but not limited to: number of simulated patients evacuated from the affected smoke compartment to a unaffected smoke compartment, time to complete simulated evacuation of patients, specific type of fire simulated, specific location of simulated fire type, and staff performance.
3. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., fire drill documentation presented to the surveyor's by the facility showed that an actual event was used as a fire drill for the facilities 2nd quarter day shift drill.
4. On 6/10/2015, at 10:57 a.m., surveyor's conducted a fire drill on the 3rd floor of the facility. During the drill, the surveyor noted the following problems/deficiencies: Staff were complacent, the fire alarm was silenced during the drill, there was no clear leadership during the drill, corridors within the affected smoke compartment were not cleared, corridors within the adjacent smoke compartment were not cleared and made ready to accept incoming patients, no simulated patient removal from the affected smoke compartment to a unaffected smoke compartment, and some staff did not know the location of the fire alarm pull stations within the unit they worked within.
The Fire Response Plan policy directs staff at Coquille Valley Hospital to always relocate horizontally first in fire situations, then vertically if required. During the drill conducted at 10:57 a.m., there was no relocation of patients horizontally or vertically as mentioned in the policy and staff within the unit were the fire drill was held mentioned that they have never been trained to relocate patients.
5. On 6/10/2015, at 8:10 p.m., surveyor's conducted a fire drill on the 3rd floor of the facility. During the drill, the surveyor noted the following problems/deficiencies: Staff were complacent, staff member did not know how to conduct an overhead page, the fire alarm pull stations was not initiated by 3 staff members that walked by the pull station, corridors within the affected smoke compartment were not cleared, smoke and fire doors were closed manually because the fire alarm was not immediately initiated.
The fire extinguisher was brought to the nurse station and not fire room, staff member did not know were the fire room was, the fire alarm was silenced, no clear leadership, code red announcement was completed but very faint and only repeated once, and there was no simulated patient removal from the affected smoke compartment to an unaffected smoke compartment. Staff mentioned "if we were told to evacuate patients, we would start doing that evacuation".

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff 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 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., there were no required yearly, quarterly, and monthly fire alarm inspection/maintenance reports for the Clinic Building adjacent to the Main Hospital.
2. On 6/11/2015, at 9:06 a.m., there was a missing mechanical set screw lock on the electrical breaker for the Fire Alarm Control Panel.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff 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 6/9/8/2015, during record review between 1:30 p.m. and 5:30 p.m., monthly testing and maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the fire alarm system to the adopted 1999 edition of NFPA 72 standards.
2. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., facility staff failed to maintain documentation of monthly and quarterly fire alarm testing and maintenance.
3. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., the facility failed to provide proper and complete documentation of the annual fire alarm system testing and maintenance in accordance with NFPA 72, 1999 edition, 7-5.2 standards.
4. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., there were no required annual, quarterly, and monthly inspection/maintenance reports for the Old Hospital Building.
5. On 6/10/2015, at 2:40 p.m., there was an obstructed/blocked fire alarm pull station by a cart at the Med. Surge Nurse Station.
6. On 6/10/2015, at 2:50 p.m., there was coban material taped to the fire alarm notification device within the Physician On-Call Sleep Room.
7. On 6/10/2015, at 2:53 p.m., there was a protective cover in place covering one of the fire alarm detectors within the East Building Maintenance shop.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13 for the building.
This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 18.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25).
Findings include, but are not limited to:
1. On 6/9/2015, at 3:25 p.m., there was missing automatic sprinkler protection for the exterior awning constructed of wood between the new hospital building on the old hospital building.
Plant Operations Staff mentioned to surveyors that the exterior awning was constructed with non-combustible or limited combustible wood. Plant Operations Staff could not provide any information or documentation to support the construction type of the exterior awning.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition for the 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 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., weekly and monthly testing and maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the sprinklers to the adopted 1998 edition of NFPA 25 standards.
2. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., required weekly and monthly testing and maintenance for the facilities automatic sprinkler system was not being documented/performed for the New Hospital Building and East Building (Old Building).
3. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., there was no required documentation for testing and maintenance for the smoke and fire dampers for the facility.
4. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., there was no required documentation for maintenance and testing of the smoke and fire dampers within the facility.
5. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., the facility failed to provide documentation that the water going for the fire protection system in the East Building had been repaired. Quarterly testing report (1/13/2015) and annual report (4/6/2015) indicated that the device was not functioning.
6. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., the facility failed to provide documentation that the plugged anti-freeze line for the fire protection sprinkler system in the East Building (Old Hospital) had been flushed and the system re-filled to provided adequate freeze protection. Annual testing report (4/6/2015) indicated the deficiency.
7. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., the facility failed to provide documentation that painted fire protection sprinkler heads in the East Building (Old Building) had been replaced. This deficiency was noted on the last two annual inspection reports (4/6/2015 and 4/28/2014).
8. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., the facility failed to document monthly and annual fire pump testing and maintenance.
9. On 6/10/2015, at 3:48 p.m., there were corroded automatic sprinkler heads that need to be replaced within the covered parking garage area.
10. On 6/10/2015, at 3:49 p.m., there was a damaged automatic sprinkler head that needs to be replaced within the covered parking garage area near the entrance to the parking area.
11. On 6/10/2015, at 4:06 p.m., there was a corroded automatic sprinkler head within the walk-in freezer in the kitchen that needs to be replaced.
12. On 6/10/2015, at 4:20 p.m., the pre-action sprinkler system for the IT Room had an electrical switch for the compressor that was hooked to the system that did not have a lock out on the switch. Switch was located within the Electrical Environmental Services room within the Administration Corridor.
13. On 6/10/2015, at 4:28 p.m., there was a missing sidewall sprinkler head within the spare sprinkler cabinet. Facility is required to have a minimum of 12 spare sprinkler heads or 2 of each type and temperature, which ever is greater for facilities having between 300 and 1000 sprinkler heads within the system.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Plant Operations 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 3-3, 8-4.6, 9-1).
Findings include, but are not limited to:
1. On 6/10/2015, during record review between 1:30 p.m. and 5:30 p.m., the facility failed to provide documentation of weekly and monthly maintenance and inspections on the fire protection sprinkler system for the Clinic Building adjacent to the Main Building.
2. On 6/11/2015, at 9:12 a.m., there was a missing replacement dry-sidewall sprinkler head for the buildings automatic sprinkler system.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff 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 18.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10).
Findings include, but are not limited to:
1. On 6/9/2015, at 3:40 p.m., there was only a Purple "K" fire extinguisher at the Helipad of the facility and not the required 10A 120B rated fire extinguisher for aircraft 50' - 80' in length.
2. On 6/10/2015, at 4:07 p.m., there was a missing Type K fire extinguisher for the UL 300 listed Kitchen Hood within the main Kitchen. This deficiency was noted on the Kitchen Hood Fire Protection System Report from 9/10/2012.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to prohibit the use of portable space heating devices.
This resulted in the potential for ignition of nearby combustibles (LSC 18.7.8).
Findings include, but are not limited to:
1. On 6/10/2015, at 2:48 p.m., there was a space heater that was not in use behind the door within the Nurse Breakroom adjacent to the Emergency Department.
2. On 6/10/2015, at 3:53 p.m., there was a space heater within the Video Conference Rm. of the East Building (Old Hospital) which was in the patient wing.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections for 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 6/10/2015, at 2:45 p.m., there were obstructions within the constructed clear width exit egress Surgical Hallway corridor consisting of two storage carts.
2. On 6/10/2015, at 2:48 p.m., there were obstructions within the constructed clear width exit egress corridor within the Emergency Department consisting of electrical BP machines that were plugged into electrical outlets.
3. On 6/10/2015, at 3:03 p.m., there were obstructions within the constructed clear width exit egress corridor outside of Patient Rm. 310 consisting of an easel and computer cart.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to provide safe storage for compressed gas in the facility.
This resulted in the potential for injury to staff and patients from a damaged compressed gas cylinder releasing unexpectedly. (LSC 38.3.2, NFPA 99 4.3.1.1.2).
Findings include, but are not limited to:
1. On 6/11/2015, at 8:55 a.m., there was a compressed gas cylinder that was not properly secured by evidence of only a single chain at the top of the cylinder that would allow the bottoms of the cylinder to kick out and strike other cylinders or walls within Procedure Rm #1 during a seismic event.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Plant Operations 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. (LSC 18.3.2.4, NFPA 99 4.3.1.1.2).
Findings include, but are not limited to:
1. On 6/10/2015, at 2:30 p.m., there were multiple compressed gas cylinders being stored within an alcove within the Surgical Suite Recover area that had electrical outlets within 60" of the finish floor.
Based on observations and interviews during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to provide safe storage for compressed gas in the facility.
This resulted in the potential for injury to staff and patients from a damaged compressed gas cylinder releasing unexpectedly. (LSC 18.3.2.4, NFPA 99 4.3.1.1.2). Findings include, but are not limited to:
2. On 6/10/2015, at 3:40 p.m., there were compressed gas cylinders that were not properly secured by evidence of the cylinders standing in a free non-restrained fashion that would allow the cylinders to fall and strike other cylinders or walls within the East Building Doctor's Office adjacent to the door going into the office.

Based on record review and interview during the survey, it was determined through on-going dialog with the Plant Operations 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 6/9/2015, during record review between at 1:30 p.m. to 5:30 p.m., the humidity policy (Maintaining a Safe, Functional Environment, EC.02.06.01) dated 5/2012 that was presented to the surveyor provide a humidity range of 35% - 60%.
Facility personnel could not provide humidity logs prior to January 2014 because the humidity was being monitored by a computer system. Humidity logs that were presented and reviewed showed the following days that the humidity was measured out of adopted range: OR #1 on 12/30-31/2014, 1/21/2015 and 5/11/2015.
Policy EC.02.06.01 states that "temperature and humidity conditions shall be monitored and recorded daily in anesthetizing locations" and "each anesthetizing location shall be equipped with a reliable measuring devices capable of displaying present temperature and humidity conditions.
Measuring devices shall be calibrated or replaced annually". Facility could not provide any documentation on the recalibration of replacement of the temperature and humidity devices used within the facility. Policy EC.02.06.01 states, "In the event of an unsatisfactory test result or discovery or a system that is not functioning properly, the infection control department and the affected area(s) or department(s) will be notified immediately, an appropriate corrective action plan shall be documented, follow-up testing and inspections shall be performed and documented prior to re-commissioning the space".
Facility could not provide any documentation on the day's the humidity was measured out of the adopted range.

Based on observations, record review and interviews it was determined through on-going dialog with the Plant Operations Staff that the facility failed to properly maintain the generator affecting the entire facility.
This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2).
Findings include, but are not limited to:
1. On 6/9/2015, during record review, between 1:30 p.m. and 5:30 p.m., monthly maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the generator the adopted 1999 edition of NFPA 110 standards.
2. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., the required 3-year, 4-hour load bank test was completed on 4/8/2015, was not completed to the requirements within NFPA 110. The load bank test was not at a minimum of 4-hours at 80% of the nameplate of the generator.
3. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., there was no weekly electrolyte testing and monthly specific gravity testing for the 125 kW generator.
4. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., there was no documentation of the required monthly specific gravity checks for February 2015, January 2015, December 2014, November 2014, September 2014, July 2014, June 2014, March 2014 and January 2014.
5. On 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., there was no documentation of the required weekly water or electrolyte checks for both generators for the year 2012 and 2013.
6. On 6/9/2015, at 3:20 p.m., there was no emergency generator stop button installed outside of the generator enclosure.
7. On 6/9/2015, at 3:20 p.m., there was no required battery powered task illumination at the 300 kW generator.
8. On 6/9/2015, at 3:30 p.m., there were maintenance free batteries installed on the 125 kW generator for the old building.

Based on record review and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff that the facility failed to provide an alternate source of power in accordance with NFPA 99 3.6, which 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 6/9/2015, during record review between 1:30 p.m. and 5:30 p.m., there was no documentation showing the required monthly 30 second test or annual 90 minute test on emergency lights within the generator enclosure or generator transfer switch.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff 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 patients & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 6/10/2015, at 2:38 p.m., there was a relocatable power tap on the floor within the Anesthesia Office.
2. On 6/10/2015, at 2:50 p.m., there was a household grade microwave within the Physician's On-Call Sleep Room.
3. On 6/10/2015, at 2:57 p.m., there was a relocatable power tap (RPT) on the wall behind the bench grinder within the East Building Maintenance Shop that was exposed to metal fillings and metal shards as evidence of the fillings and shards found within the outlets of the RPT.
4. On 6/10/2015, during the facility tour between 3:00 p.m. and 4:00 p.m., there was exposed energized electrical wiring within the East Building (Old Hospital) noted in the following locations but not limited to: Women's OR Dressing Room, OR area, OB area, Lab and Kitchen.
5. On 6/10/2015, at 3:42 p.m., there were two household hotplate devices within a servery room adjacent to the Conference/Board Room.
6. On 6/10/2015, at 3:42 p.m., there was a relocatable power tap (RPT) within the Nurse's Office in the East Building (Old Hospital) that was not equipped with overcurrent protection.
7. On 6/10/2015, at 3:45 p.m., there was an extension cord in use powering a light within the Maintenance Office.
8. On 6/10/2015, at 3:45 p.m., there was a relocatable power tap (RPT) on the floor within the Maintenance Office.
9. On 6/10/2015, at 3:55 p.m., there Fire Alarm Control Panel breaker within panel LSL2 was painted and needs to be replaced.
10. On 6/10/2015, at 4:20 p.m., there were multiple relocatable power taps (RPT's) on the floor within Administration and IT areas.

Based on observations and interview during the survey, it was determined through on-going dialog with the Plant Operations Staff 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 patients & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 6/11/2015, at 8:45 a.m., there was an open electrical junction box on the 2nd floor/storage floor near the SE corner of the building.
2. On 6/11/2015, at 8:58 p.m., there was a 6:2 cube adapter plugged into an electrical outlet within the Exam/PR room (Rm. #20).
3. On 6/11/2015, at 9:04 p.m., the electrical breaker for the Fire Alarm Control Panel was painted and needs to be replaced.