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Based on observations, record review and interviews during the survey, it was determined through on-going dialog with the Facility Manager and (2) Corporate Program Managers that the facility failed to comply with the Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482).

Findings include:
On 7/12/22, during documentation review between the hours of 1:20 pm and 3:20 pm,the facility failed to provide to this surveyor the necessary annual program review needed to ensure compliance.

Surveyor was accompanied by the Facility Manager and (2) Nurse Managers, and other hospital staff members who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Manager and (2) Corporate Program Managers that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482).

Findings include:
On 7/12/22, during documentation review between the hours of 1:20 pm and 3:20 pm, the facility failed to provide evidence of a documented process for cooperation and collaboration with local, tribal, regional, state and federal EP officials.

Surveyor was accompanied by the Facility Manager and (2) Nurse Managers, and other hospital staff members who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Manager and (2) Corporate Program Managers that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482).

Findings include:
On 7/13/22, during documentation review between the hours of 9:20 am and 1:14 pm, the facility failed to develop and implement EP policies and procedures, based on their reported all-hazards and vulnerability assessment within their established and communicated plan.

Surveyor was accompanied by the Facility Manager and (2) Nurse Managers, and other hospital staff members who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Manager and (2) Corporate Program Managers that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482).

Findings include:
On 7/13/22, during documentation review between the hours of 9:20 am and 1:14 pm, the facility failed to provide evidence of a secure and stable patient environment in the event of an elongated emergency, to include: (1)(i) defined policies and/or protocols for medical, and pharmaceutical supplies of staff, and (D) sewage and/or waste disposal capable of supporting the length of time the facility has chosen to shelter-in-place, as identified within the facility's EP plan.

Surveyor was accompanied by the Facility Manager and (2) Nurse Managers, and other hospital staff members who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Manager and (2) Corporate Program Managers that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482).

Findings include:
On 7/13/22, during documentation review between the hours of 9:20 am and 1:14 pm, the facility failed to produce the required contact information for local, tribal, regional, state, and federal EP supportive agencies within their established comprehensive EP Communications Plan.

Surveyor was accompanied by the Facility Manager and (2) Nurse Managers, and other hospital staff members who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Manager and (2) Corporate Program Managers that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482).

Findings include:
On 7/13/22, during documentation review between the hours of 9:20 am and 1:14 pm, the facility failed to properly identify both primary and secondary means of communication with federal, state, regional, and local emergency preparedness supportive agencies within the EP plan.

Surveyor was accompanied by the Facility Manager and (2) Nurse Managers, and other hospital staff members who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Manager and (2) Corporate Program Managers that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482).

Findings include:
On 7/13/22, during documentation review between the hours of 9:20 am and 1:14 pm, the facility failed to provide a documented policy and/or procedure outlining an Emergency Preparedness Training and Testing Program based on expected roles defined within the established Emergency Preparedness Plan.

Surveyor was accompanied by the Facility Manager and (2) Nurse Managers, and other hospital staff members who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Manager and (2) Corporate Program Managers that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482).

Findings include:
On 7/13/22, during documentation review between the hours of 9:20 am and 1:14 pm, the facility failed to document and communicate the necessary training and testing to include, but not limited to, (i) all new and existing staff, (ii) external sources providing services under agreement, and/or (iii) volunteers, consistent with their expected roles within the EP plan, based on defined all-hazards scenarios.

Surveyor was accompanied by the Facility Manager and (2) Nurse Managers, and other hospital staff members who acknowledged the existence of these findings.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Manager and (2) Corporate Program Managers that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 482).

Findings include:
On 7/13/22, during documentation review between the hours of 9:20 am and 1:14 pm, (e)(3) the facility failed to provide documentation outlining continuing fuel support for the diesel generator in the event of an elongated emergency.

Surveyor was accompanied by the Facility Manager and (2) Nurse Managers, and other hospital staff members who acknowledged the existence of these findings.

Based on observations during the survey, it was determined through on-going dialog with the Facility Manager that the facility failed to meet construction types for nonbearing walls for a single smoke compartment of the building. This resulted in the potential for uncontrolled smoke and heat migration into the other parts of the building in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 19.1.6.4 and 19.1.6.5).

Findings include:

1. On 07/12/2022, at 9:27 am, there were unsealed opening(s)/penetration(s) in the ceiling of the CT Room that would allow products of combustion (smoke and heat) into the concealed space during a hostile fire event.

2. On 07/12/2022, at 9:48 am, there were unsealed opening(s)/penetration(s) in the ceiling of the ED EVS Room that would allow products of combustion (smoke and heat) into the concealed space during a hostile fire event.

3. On 07/12/2022, at 10:15 am, there were unsealed opening(s)/penetration(s) in the wall and ceiling of the Old Boiler Room that would allow products of combustion (smoke and heat) into the concealed space during a hostile fire event.

4. On 07/12/2022, at 10:53 am, there were unsealed opening(s)/penetration(s) in the ceiling behind the stove in the Kitchen that would allow products of combustion (smoke and heat) into the concealed space during a hostile fire event.

5. On 07/12/2022, at 10:58 am, there were unsealed opening(s)/penetration(s) in the wall under the sink of the Dishwashing Room that would allow products of combustion (smoke and heat) into the concealed space during a hostile fire event.

6. On 07/12/2022, at 11:05 am, there were unsealed ceiling and wall opening(s)/penetration(s) in multiple locations in the corridors and rooms of the Old ED that would allow products of combustion (smoke and heat) into the concealed space during a hostile fire event.

7. On 07/12/2022, at 12:10 pm, there were unsealed opening(s)/penetration(s) in the wall of the Admin Basement that would allow products of combustion (smoke and heat) into the concealed space during a hostile fire event.

8. On 07/12/2022, at 12:25 pm, there were unsealed opening(s)/penetration(s) in the wall of Med Room 1153 that would allow products of combustion (smoke and heat) into the concealed space during a hostile fire event.

9. On 07/12/2022, at 12:26 pm, there were unsealed opening(s)/penetration(s) in the ceiling of the Med Gas Room that would allow products of combustion (smoke and heat) into the concealed space during a hostile fire event.

10. On 07/12/2022, at 12:47 pm, there were multiple unsealed opening(s)/penetration(s) in the Electrical Old ED in the Basement that would allow products of combustion (smoke and heat) into the concealed space during a hostile fire event.

11. On 07/12/2022, at 12:47 pm, there were unsealed opening(s)/penetration(s) in the FACP Room that would allow products of combustion (smoke and heat) into the concealed space during a hostile fire event.

Surveyor was accompanied by the Facility Manager, Corporate Managers and Hospital Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Manager that the facility failed to install proper hold-open devices that will release on the actuation of the fire alarm system, fire sprinkler system or power loss for the entire building. This resulted in the potential for smoke and fire to spread to other areas of the facility (LSC 7.2.1.8.2, 18/19.2.2.2.7, 18/19.2.2.2.8).

Findings include:

On 07/12/2022 at 12:55 pm, there was a unapproved hold open device (door wedge) not connected to the fire alarm or fire sprinkler system of the facility at the fire rated door to Room 1117.

Surveyor was accompanied by the Facilities Manager, Corporate Managers and who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facility Manager the facility failed to ensure that hazardous suites, rooms, or areas are separated from the remainder of the building by construction meeting the separation provisions for corridor construction. This resulted in the potential of transfer of smoke or fire to other areas within the facility.

Findings include:

On 7/12/2022, during survey of physical environment between 9:00 am and 2:30 pm, the Old ED area use was changed to combustible storage. A wall was constructed without evidence that it meets fire rating requirements for this type of use.

Surveyor was accompanied by the Facility Manager, Corporate Managers and Hospital Staff who acknowledged the existence of these findings.

Based on observation and interviews during the survey, it was determined through on-going dialog with the Facilities Manager that the facility failed to maintain compliant hazardous area fire separation (for 2 of the 4 sampled smoke compartments) within the building. This resulted in the potential for patients & staff to be exposed to hazardous byproducts of fire during a hostile fire event (LSC 18.3.2.1, 9.7, 8.7, 8.4, and 7.2.1.8).

Findings include:

On 07/12/2022, at 12:30 pm, the facility was found to be storing flammables and combustible materials within the maintenance shop and not in the required hazardous materials cabinet.

Surveyor was accompanied by the Facilities Manager, Corporate Managers, and Hospital Staff who acknowledged the existence of these findings.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Manager and Hospital Staff that the facility failed to ensure that piped-in medical gas complied with NFPA 99 for the facility (NFPA 99, 5.1.4.8.7, 5.1.9.3, 6.4.2.2.4.2 & LSC 8.7, 18/19.3.2.3, S&C 13-58 and S&C 15-27). This resulted in the potential for injury to patients during medical procedures. Findings include, but were not limited to:

On 07/12/2022, during record review between 1:00 pm and 3:00 pm, the humidity policy presented specified range of 30%-60% relative humidity with procedures to follow when outside the identified range. Humidity logs presented showed multiple entries with an identified range under 30% with no documentation the procedures were followed before procedures were performed.

Surveyor was accompanied by the Facilities Manager, Corporate Managers and Hospital Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Manager that the facility failed to install fire alarm system in accordance with NFPA 72 public or private mode systems. This resulted in the potential for system and device failure/delay and panic during fire emergencies for the universe entire building (LSC 18/19.3.4, 18/19.3.4.1, 9.6, 9.6.1.8, NFPA 72, NFPA 70).

Findings include:

On 07/12/2022, during survey of physical environment between 7:30 am and 2:00 pm, there were no notification devices in multiple rooms where the purpose and use of the room was changed and notification devices would be required.

Surveyor was accompanied by the Facilities Manager, Corporate Managers and Hospital Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Manager that the facility failed to ensure that the facility was protected throughout by an approved automatic sprinkler system in accordance with NFPA 13 for universe 1 patient room closet of the building. This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 19.3.5, 19.3.5.1 - 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1), and NFPA 13).

Findings include:

On 07/12/2022, at 12:12 pm, there was a canopy made of combustible material outside the Administration area that was over 4 feet and attached to the building. The canopy had installed sprinkler heads, however the sprinkler system was disconnected. When interviewed, the Facilities Manager said the local AHJ indicated the system could be disconnected. Discussion ensued with the Facilities Manager that both Oregon Fire Code and CMS Requirements/NFPA 101 must be met, where there is a conflict the most stringent requirement must be met, thus this area is required to have a functioning sprinkler system.

Surveyor was accompanied by the Facilities Manager, Corporate Managers and hospital team members who acknowledged the existence of these conditions.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Facility Manager that the facility failed to ensure the automatic sprinkler and standpipe systems were continuously maintained, inspected and tested in a reliable operating condition for the universe entire building. This resulted in the potential for system failure during fire emergencies (LSC 18/19.3.5, 9.7.5, 9.7.7, 9.7.8, NFPA 25).

Findings include:

1. 07/11/2022, during record review between 3:00 pm and 5:00 pm, there was not a current record of the required 5 year maintenance and testing for the fire sprinkler system.

2. 07/11/2022, during record review between 3:00 pm and 5:00 pm. and confirmed during physical environment walk through, the gauges on the fire sprinkler riser were dated 2016 and were past due for replacement or recalibration.

3. 07/12/2022, at 10:41 am, there was a gap between the fire sprinkler escutcheon and the ceiling in the Nurse Manager Storage Room.

4. 07/12/2022, at 10:41 am, there was a gap between the fire sprinkler escutcheon on both the interior of the walk in cooler and the outside wall by the cooler door.

5. 07/12/2022, at 12:44 pm, there was a loaded fire sprinkler in the Closet/Room 1116.

Surveyor was accompanied by the Facilities Manager, Corporate Managers and hospital team members who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Manager that the facility failed to select, install, inspect and maintain fire extinguishers in accordance with adopted standards for universe all extinguishers of the facility. This resulted in the potential for fires to progress beyond incipient stage (LSC 19/18.3.5.12, NFPA 10).

Findings include:

1. On 07/12/2022, at 12:34 pm, the portable fire extinguisher located on the back side of the maintenance room was blocked by storage and obstructed or obscured from view.

2. On 07/12/2022, at 12:36 pm, there was no portable fire extinguisher visible and readily available within 75 feet of the LPG tank.

Surveyor was accompanied by the Facility Manager, Corporate Managers and Hospital Staff who acknowledged the existence of these conditions.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Facility Manager and Corporate Manager 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 18/19.7.1.4 - 18/19.7.1.7).

Findings include:

1. On 07/11/2022, during record review between 2:00 pm and 4:00 pm, through on-going dialog with facility staff it was determined that fire drills were not being conducted as "unannounced".

2. On 07/12/2022, during record review between 2:00 pm and 3:00 pm, facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as but not limited to the number of simulated occupants evacuated from the affected smoke compartment, time to complete the simulated evacuation from the affected smoke compartment to an unaffected smoke compartment, specific type of fire simulated, and specific location of simulated fire.

Surveyor was accompanied by the Facilities Manager, Corporate Managers and hospital team members who acknowledged the existence of these conditions.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facilities Manager that the facility failed to maintain approved fire-rated doors within the building. This resulted in the potential for the spread of fire/smoke to other compartments (LSC 20/21 and 8).

Findings include:

1. On 7/12/2022 at 10:04 am, a rated fire door to the Galleria EVS Room did not close and latch properly.

2. On 7/12/2022 at 10:59 am, a rated fire door to the Dishwashing Room did not close and latch properly.

Surveyors were accompanied by the Facility Administrator, Corporate Managers, and Hospital Staff who acknowledged the existence of these findings.

Based on observations and interviews it was determined through on-going dialog with the Facilities Manager that the facility failed to properly maintain Electrical Systems and Receptacles affecting 1 sampled smoke compartment within the building. This resulted in the potential for the lack of emergency electrical power during an emergency event 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99).

Findings include:

On 07/11/2022, during record review between 3:00 pm and 5:00 pm, the facility failed to provide documentation for the required annual receptacle testing to ensure proper grounding and connections. The facility has a mix of medical grade and non-medical grade outlets. When interviewed by the surveyor, the Facilities Manager acknowledge the tests had not been performed and was unaware of the requirement.

Surveyor was accompanied by the Facilities Manager, Corporate Managers and hospital team members who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with the Facilities Manager 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:

On 07/11/2022, during record review between 3:00 pm and 5:00 pm, facility did not provide current documentation for the required annual fuel testing.

Surveyor was accompanied by the Facility Manager, Corporate Managers and Hospital Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facilities Manager that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for 2 of 2 sampled smoke compartments of the building. This resulted in the potential for injury to residents & staff (LSC 9.1.2, NFPA 99 10.2.3.6, 10.2.4, NFPA 70, TIA 12-5).

Findings include:

On 07/12/2022, during survey of physical environment between 09:00 am and 2:30 pm, there were Relocatable Power Tap(s) (RPT) permanently attached to the facility walls that required the use of tool for removal or on the floor throughout the facility. Locations such as but no limited to: Tech Area, Reading Room, Training Room, Chart Station #124.

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

Based on observations, record review and interviews it was determined through on-going dialog with the Facilities Manager 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 and was found repeated throughout the building. (LSC 18.3.2.4, NFPA 99 4.3.1.1.2).

Findings include:

1. On 7/12/2022, at 9:56 am, oxygen cylinders were found stored within Triage Room in the ER.

2. On 7/12/2022, at 1:16 pm, (10) oxygen cylinders were found stored within Respiratory Therapy Room.

3. On 07/22/2022 at 1:17 pm, the facility failed to provide a separation from combustibles 5 feet or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating in the Oxygen Storage Room.

Surveyor was accompanied by the Facilities Manager, Corporate Managers, and Hospital Staff who acknowledged the existence of these findings.