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Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director 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:

1. On 11/17/2017, at 09:10 a.m., the facility failed to provide the surveyor a humidity policy or humidity log history of daily entries. On 07/20/17 at 10:15 a.m. a revised humidity policy (dated 07/20/17) was presented to the surveyor. The policy had an adopted a specified range between 30%-60% relative humidity.

Surveyor was accompanied by the Maintenance Director 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 Maintenance Director 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, but were not limited to:

1. On 07/19/17 between 9:10 a.m. and 9:30 a.m., facility director advised surveyor that Reedsport Medical Center (RMC) building (2) is a satellite location for Lower Umpqua Hospital in regards to Fire Drill policy and conducting fire drills. The facility director did not present a fire drill policy or fire drill records for the RMC satellite location.

Surveyor was accompanied by the Maintenance Director 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 Maintenance Director that the facility failed to ensure safe smoking practices by residents in the facility in accordance with facility policies and life safety regulations. This resulted in the potential for exposing residents to a fire and/or smoke environment (LSC 19/18.7.4). Findings include, but were not limited to:

1. On 07/18/2017, during record review between 9:10 a.m. and 9:30 a.m. the facility smoking policy was not followed by staff and residents or enforced as evidenced by the following: smoking materials were found to be in unapproved receptacles within the staff smoking area and inside the boundaries of the open campus. The facility had established smoking areas within close of proximity to combustible flammable gas storage to include Liquefied Petroleum (LPG) and Oxygen storage containers.

2. On 11/19/2017, during survey of the facility satellite building referred to as Reedsport Medical Center (RMC) building (2), it was observed between 9:35 a.m. and 10:10 a.m. the facility smoking policy was not followed by either staff and or residents nor was the policy enforced as evidenced by the following: smoking materials were found to be discarded within unapproved receptacles and within the staff smoking area of the exterior grounds of building 2.

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

Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for 1 of 1 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, but were not limited to:

1. On 03/19/2017, at 09:40 a.m., there was an unapproved Re-locatable Power Tap (RPT) in use in patient exam room of Dr. Atkinson in Reedsport Medical Center (RMC) building (2).

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