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Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and 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 or concealed spaces 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 7/8/2015, at 8:48 a.m., there were unsealed wall and ceiling penetrations within the Electrical Room adjacent to the Administration Area that would allow products of combustion to enter the attic space of the building.
2. On 7/8/2015, at 9:25 a.m., there were unsealed wall penetrations in the 2-hr. wall between the Long Term Care Facility and Hospital within the South Attic area.
3. On 7/8/2015, at 9:40 a.m., there was an unsealed wall penetration in the 2-hr. wall between the Hospital and the Clinic Building around the fire protection sprinkler pipe above the door adjacent to the Coffee Cart.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to maintain the integrity of smoke separations.
This resulted in the potential for uncontrolled smoke migration into the egress corridor or concealed spaces in the event of a fire, causing the exposure of patients & staff to hazardous products of fire (LSC 39.3.1, .2, .5).
Findings include, but are not limited to:
1. On 7/8/2015, at 8:05 a.m., there were ceiling penetrations within the wash room off the large Conference Room within the Sleep Lab Area that would allow products of combustion into the attic space of the building.
2. On 7/8/2015, during record review between 1:00 p.m. and 2:00 p.m., surveyors discovered after talking with the facilities engineer of record, remodeling that was being completed within the Rural Health Clinic had not been submitted to Facilities Planning and Safety.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to maintain exit corridor doors resist the passage of smoke into the means of egress in the event of a hostile fire event (LSC 18.2.3.5, Table 18.3.2.1, 18.3.6.3, Exception 2; A18.3.6.3.3).
Findings include, but are not limited to:
1. On 7/8/2015, at 9:42 a.m., there were a set of cross-corridor smoke compartment doors adjacent to the Sterile Processing Room, that were not closing properly. The south leaf of the smoke compartment doors was dragging on the north leaf and not closing completely.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and 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 7/8/2015, at 8:52 a.m., there was a soiled utility room door adjacent to the Rehab Area that 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 Director of Plant Operations and Plant Operations Staff that the facility failed to maintain accessible exits for the building as required by 2000 NFPA 101, 18.2.2.2.4.
This resulted in the potential for panic and injury to occupants.
Findings include, but are not limited to:
1. On 7/8/2015, at 8:22 a.m., the direct exterior exit from the Labor and Delivery unit was obstructed on the exterior of the building by a pallet of "Smurf Tube".

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to maintain accessible exits for the building as required by 2000 NFPA 101, 39.2.2.2.4.
This resulted in the potential for panic and injury to patients and occupants.
Findings include, but are not limited to:
1. On 7/82015, at 7:56 a.m., there were approximately 4 exit lights within the Rural Health area that did not work when the test button was pushed by the surveyor.
2. On 7/8/2015, at 7:58 a.m., there were approximately 2 exit lights within the Sleep Lab area that did not work when the test button was pushed by the surveyor.
3. On 7/8/2015, at 8:06 a.m., there was an exit light within the corridor outside of the Sleep Lab area that did not work when the test button was pushed by the surveyor.
4. On 7/8/2015, at 8:15 a.m., there were approximately 3 exit lights within Lake Health Clinic that did not work when the test button was pushed by the surveyor.
5. On 7/8/2015, at 1:13 p.m., there was a dead-bolt lock with a thumb lock on the double doors between the patient treatment area and patient reception area within the Lake Health Clinic.
6. On 7/8/2015, at 1:13 p.m., there was a slide bolt style lock on the west leaf of the double doors between the patient treatment area and patient reception area within the Lake Health Clinic that shall be removed.

Based on record review and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and 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 18.2.8).
Findings include, but are not limited to:
1. On 7/7/2015, during record review between 11:30 a.m. and 6:00 p.m., facility staff informed surveyor's that monthly 30 second testing and annual 90 minute testing for the emergency lights within the OR's have not been maintained or tested.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Director of Plant Operations and 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, A18.7.1.2).
Findings include, but are not limited to:
1. On 7/7/2015, during record review between 11:30 a.m. and 6:00 p.m., the facility had no documentation on conducting their 1st quarter day shift fire drill for 2015.
2. On 7/7/2015, during record review between 11:30 a.m. and 6:00 p.m., the facility had no documentation on conducting their 1st quarter and 2nd quarter night shift drills for 2015.
3. On 7/8/2015, during record review between 11:30 a.m. and 6:00 p.m., facility documentation presented to the surveyor by the facility showed that fire drills for night shift in 2014 and 2015 were not completed under varying conditions and random times throughout the shift.
Fire drills were conducted between 10:00 p.m. and 11:10 p.m. and multiple drills were conducted on the 30th day of the month, which demonstrates that fire drills were conducted in a manner that created a pattern, instead of on different days and times and involving different locations and simulated circumstances.
4. On 7/8/2015, at 2:23 p.m., surveyor's had Plant Operations Staff conduct a fire drill. During the fire drill surveyor's noted the following problems with the fire drill: Staff did not simulate the evacuation of patients from the affected smoke compartment to a unaffected smoke compartment, staff did not clear the corridors within the affected smoke compartment of obstructions such as housekeeping carts, desk chairs and med carts, corridors were not cleared in adjoining smoke compartments to ready the compartment for the acceptance of evacuated patients, there was no fire extinguisher brought to the simulated fire room, staff had to be coached by Plant Operations Staff on what they were suppose to do, there was no clear leadership, there was no announcement of which room had the simulated fire and staff had to be coached to activate the fire alarm pull station.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to install fire alarm system in accordance with NFPA 72 systems.
This resulted in the potential for delay and panic during fire emergencies (LSC 39.3.4, 39.3.4.2, 9.6, NFPA 72).
Findings include, but are not limited to:
1. On 7/8/2015, at 8:10 a.m., there were fire alarm pull stations within the Lake Health Clinic that were mounted approximately 63" and 62" from the finish floor which was more then the required height of 42" - 48" from finish floor.
Fire alarm pull stations were located within the north and south parts of the building.
2. On 7/8/2015, at 8:10 a.m., there were fire alarm pull stations within the Lake Health Clinics that were not installed within 5' of the egress door as required by NFPA 72.
Fire alarm pull station were located within the north and south parts of the building.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to test and maintain the fire alarm in accordance with NFPA 72.
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 7/8/2015, at 8:03 a.m., there was a blocked fire alarm pull station by a bed table adjacent to the south exit from the Sleep Lab area.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to test and maintain fire alarm in accordance with NFPA 72.
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 7/7/2015, during record review between 11:30 a.m. and 6:00 p.m., there was no documentation provided to the surveyor's showing monthly fire alarm inspection and maintenance by either Plant Operations Staff or a Third Party Vendor.
2. On 7/8/2015, at 11:30 a.m., the electrical breaker for the fire alarm sub-panel box located within the corridor outside of the Rural Health Clinic did not have a set screw lock on the electrical breaker (Panel H, breaker #19).
3. On 7/8/2015, at 2:24 p.m., during the fire drill, the surveyor noted that the fire alarm visual notification devices within the Rock Garden area and Scullery Hall adjacent to the Gift Shop were not synchronized.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13.
This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 39.3.2 NFPA 13 5-6.3.3, .4, NFPA 25).
Findings include, but are not limited to:
1. On 7/8/2015, at 7:45 a.m., there was missing required automatic sprinkler coverage in the exterior awning outside the main entrance of the Rural Health Building.
2. On 7/8/2015, at 7:45 a.m., there was missing required automatic sprinkler coverage within the covered entrance to the Rural Health Building.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations 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 7/8/2015, at 8:30 a.m., there was a missing spare stock of sidewall sprinkler heads within the spare sprinkler cabinet that served the sprinkler system for the Sleep Lab.
Facility was required to maintain a minimum of 6 spare heads or two of each type and temperature whichever was greater.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and 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 7/7/2015, during record review between 11:30 a.m. and 6:00 p.m., there was no documentation provided to the surveyor's showing weekly fire sprinkler inspection and maintenance by either Plant Operations Staff or a Third Party Vendor for March and April 2015.
2. On 7/7/2015, during record review between 11:30 a.m. and 6:00 p.m., there was no documentation provided to the surveyor's showing monthly fire sprinkler inspection and maintenance by either Plant Operations Staff or a Third Party Vendor for December 2014 and June 2015.
3. On 7/8/2015, at 9:30 a.m., there was insulation material dislodged from the above roof deck that was creating an obstruction to the automatic sprinkler head within the North Attic area.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to maintain or install 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 7/8/2015, at 9:50 a.m., there was not a minimum required 10A 120B sized fire extinguisher located at the facilities Helistop. The fire extinguisher located at the Helistop was a Purple K extinguisher.
2. On 7/8/2015, at 10:19 a.m., the fire extinguisher within the Laboratory Area was only a B, C rated fire extinguisher and not the minimum required 2A, 10B:C rated fire extinguisher.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to ensure that no combustibles or decorations of highly flammable character are used, or stored improperly within the building.
This resulted in the potential for excessive fire spread (LSC 39.3.2, 7.12, NEC 70).
Findings include, but are not limited to:
1. On 7/8/2015, at 8:12 a.m., there were combustible materials (cardboard boxes, paper products, etc.) stored within 24" of the ceiling throughout the unsprinklered Lake Health Clinic area including but not limited to Rm. 4 and the Record Storage Room.
2. On 7/8/2015, at 8:15 a.m., there were combustible materials (cardboard and paper) stacked and piled around the water heater within the Record Storage Room of Lake Health Clinic.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to provide safe storage for compressed gas cylinders in the facility.
This resulted in the potential for injury to staff and residents from a damaged compressed gas cylinder releasing unexpectedly. (LSC 39.3.2.4, NFPA 99 4.3.1.1.2).
Findings include, but are not limited to:
1. On 7/8/2015, at 8:02 a.m., there were 4-compressed gas cylinders that were not properly secured by evidence of the cylinders standing in a free non-restrained fashion that would allow the bottoms of the cylinders to kick out and strike other cylinders or walls within the Clean Room of the Sleep Lab during a seismic event.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to ensure that piped in medical gas systems comply with NFPA 99.
This resulted in the potential for injury to patients during medical procedures.
Findings include but are not limited to:
1. On 7/8/2015, at 7:52 a.m., there was warning/caution signage at the Liquid Oxygen Storage tank that was weathered and faded that shall be replaced.
Signage needs to meet the requirements of NFPA 99, 1999 edition, Section 4-3.1.1.7 and NFPA 50, 1996 edition, Section 3-5.8.

Based on record review and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1 (S&C 13-25 LSC)
This resulted in the potential for injury to patients during medical procedures.
Findings include, but are not limited to:
1. On 7/7/2015, during record review between at 11:30 a.m. and 6:00 p.m., the facility failed to provide Humidity monitoring logs for the anesthetizing locations for the hospital. Staff indicated that there were no Humidity Logs being kept and that the system was monitored by a computerized system.
A log of average OR Humidity, that was monitored by the HVAC system was provided and showed only 22 entries from 4/9/2014 to 7/7/2015. There were 16 entries that showed the humidity measured below 35% and 9 entries that showed the humidity measured below 30%.
Facility staff indicated that they did not have a humidity policy and provided a chart that outlines the humidity range that was monitored and the facility identified 30% relative humidity as their adopted range.
The facility also did not address what the facility would do or who the facility would notify when the humidity was not within the adopted acceptable range.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to maintain the installation of blanket warmers for the facility, complying with NFPA 99, 1999 ed. Section 9-2.1.8.1(l)

This resulted in the potential for unexpected ignition source & excessive fire spread.

Findings include, but are not limited to:

1. On 07/8/2015, between 8:36 and 9:46 a.m., there were combustible items stored on top of and against blanket warmers in the Acute Care Linen Room and ER Consultation Room.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to maintain the installation of the Liquid Propane Gas Vaporizer in accordance with NFPA 58, 2004 ed., Section 6.11.

This resulted in the potential for unexpected ignition of expanding liquid propane and failure of the gas piping system.

Findings include, but are not limited to:

2. On 07/08/2015 at 7:49 a.m., there was liquid piping to the electric LPG Vaporizer that could impound liquid propane between control valves without over pressurization protection from a hydrostatic relief valve.

Based on record review and interviews it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to properly maintain the generator for 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 7/7/2015, during record review between 11:30 a.m. and 6:00 p.m., there was no documentation provided to the surveyor's showing monthly emergency generator inspection and maintenance by either Plant Operations Staff or a Third Party Vendor for December 2014, March 2015, April 2015 and May 2015.
2. On 7/7/2015, during record review between 11:30 a.m. and 6:00 p.m., there was no documentation provided showing the required weekly electrolyte and monthly specific gravity testing on the emergency generator batteries.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and 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 residents & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 7/8/2015, at 7:47 a.m., there were multiple open electrical junction boxes within the Chiller Room of the Facility CUP.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70.
This resulted in the potential for injury to patients & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 7/8/2015, at 8:02 a.m., there was compressed gas cylinders being stored within the Clean Room Storage closet within the Sleep Lab area that had electrical outlets/switches within 60" of the finish floor.
2. On 7/8/2015, at 8:20 a.m., there were multiple relocatable power taps (RPT's) on the floor within the Lake Health Clinic.
3. On 7/8/2015, at 8:25 a.m., there was a household grade microwave, toaster and coffee maker within the Staff Breakroom of the Lake Health Clinic.

Based on the observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and 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 patients 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 7/8/2015, at 7:28 a.m., there was an alcohol based hand rub (ABHR) dispenser installed above an electrical light switch within the OR Corridor outside of OR #2.
2. On 7/8/2015, during the facility tour between 8:44 a.m. and 10:30 a.m., there were alcohol based hand rub (ABHR) dispensers installed above electrical outlets and or electrical light switches within the following locations but not limited to: Vestibule for Isolation Rooms, Patient Rm's. 106, 116, and 118, Med/IV Room, and ER Soiled Utility.
3. On 7/8/2015, at 9:40 a.m., there were alcohol based hand rub (ABHR) dispensers installed above an electrical outlet adjacent to the Employee Time Clock and above an electrical light switch within the Doctor's Sleep Rm.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and 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 or concealed spaces 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 7/8/2015, at 8:48 a.m., there were unsealed wall and ceiling penetrations within the Electrical Room adjacent to the Administration Area that would allow products of combustion to enter the attic space of the building.
2. On 7/8/2015, at 9:25 a.m., there were unsealed wall penetrations in the 2-hr. wall between the Long Term Care Facility and Hospital within the South Attic area.
3. On 7/8/2015, at 9:40 a.m., there was an unsealed wall penetration in the 2-hr. wall between the Hospital and the Clinic Building around the fire protection sprinkler pipe above the door adjacent to the Coffee Cart.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to maintain the integrity of smoke separations.
This resulted in the potential for uncontrolled smoke migration into the egress corridor or concealed spaces in the event of a fire, causing the exposure of patients & staff to hazardous products of fire (LSC 39.3.1, .2, .5).
Findings include, but are not limited to:
1. On 7/8/2015, at 8:05 a.m., there were ceiling penetrations within the wash room off the large Conference Room within the Sleep Lab Area that would allow products of combustion into the attic space of the building.
2. On 7/8/2015, during record review between 1:00 p.m. and 2:00 p.m., surveyors discovered after talking with the facilities engineer of record, remodeling that was being completed within the Rural Health Clinic had not been submitted to Facilities Planning and Safety.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to maintain exit corridor doors resist the passage of smoke into the means of egress in the event of a hostile fire event (LSC 18.2.3.5, Table 18.3.2.1, 18.3.6.3, Exception 2; A18.3.6.3.3).
Findings include, but are not limited to:
1. On 7/8/2015, at 9:42 a.m., there were a set of cross-corridor smoke compartment doors adjacent to the Sterile Processing Room, that were not closing properly. The south leaf of the smoke compartment doors was dragging on the north leaf and not closing completely.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and 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 7/8/2015, at 8:52 a.m., there was a soiled utility room door adjacent to the Rehab Area that 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 Director of Plant Operations and Plant Operations Staff that the facility failed to maintain accessible exits for the building as required by 2000 NFPA 101, 18.2.2.2.4.
This resulted in the potential for panic and injury to occupants.
Findings include, but are not limited to:
1. On 7/8/2015, at 8:22 a.m., the direct exterior exit from the Labor and Delivery unit was obstructed on the exterior of the building by a pallet of "Smurf Tube".

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to maintain accessible exits for the building as required by 2000 NFPA 101, 39.2.2.2.4.
This resulted in the potential for panic and injury to patients and occupants.
Findings include, but are not limited to:
1. On 7/82015, at 7:56 a.m., there were approximately 4 exit lights within the Rural Health area that did not work when the test button was pushed by the surveyor.
2. On 7/8/2015, at 7:58 a.m., there were approximately 2 exit lights within the Sleep Lab area that did not work when the test button was pushed by the surveyor.
3. On 7/8/2015, at 8:06 a.m., there was an exit light within the corridor outside of the Sleep Lab area that did not work when the test button was pushed by the surveyor.
4. On 7/8/2015, at 8:15 a.m., there were approximately 3 exit lights within Lake Health Clinic that did not work when the test button was pushed by the surveyor.
5. On 7/8/2015, at 1:13 p.m., there was a dead-bolt lock with a thumb lock on the double doors between the patient treatment area and patient reception area within the Lake Health Clinic.
6. On 7/8/2015, at 1:13 p.m., there was a slide bolt style lock on the west leaf of the double doors between the patient treatment area and patient reception area within the Lake Health Clinic that shall be removed.

Based on record review and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and 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 18.2.8).
Findings include, but are not limited to:
1. On 7/7/2015, during record review between 11:30 a.m. and 6:00 p.m., facility staff informed surveyor's that monthly 30 second testing and annual 90 minute testing for the emergency lights within the OR's have not been maintained or tested.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Director of Plant Operations and 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, A18.7.1.2).
Findings include, but are not limited to:
1. On 7/7/2015, during record review between 11:30 a.m. and 6:00 p.m., the facility had no documentation on conducting their 1st quarter day shift fire drill for 2015.
2. On 7/7/2015, during record review between 11:30 a.m. and 6:00 p.m., the facility had no documentation on conducting their 1st quarter and 2nd quarter night shift drills for 2015.
3. On 7/8/2015, during record review between 11:30 a.m. and 6:00 p.m., facility documentation presented to the surveyor by the facility showed that fire drills for night shift in 2014 and 2015 were not completed under varying conditions and random times throughout the shift.
Fire drills were conducted between 10:00 p.m. and 11:10 p.m. and multiple drills were conducted on the 30th day of the month, which demonstrates that fire drills were conducted in a manner that created a pattern, instead of on different days and times and involving different locations and simulated circumstances.
4. On 7/8/2015, at 2:23 p.m., surveyor's had Plant Operations Staff conduct a fire drill. During the fire drill surveyor's noted the following problems with the fire drill: Staff did not simulate the evacuation of patients from the affected smoke compartment to a unaffected smoke compartment, staff did not clear the corridors within the affected smoke compartment of obstructions such as housekeeping carts, desk chairs and med carts, corridors were not cleared in adjoining smoke compartments to ready the compartment for the acceptance of evacuated patients, there was no fire extinguisher brought to the simulated fire room, staff had to be coached by Plant Operations Staff on what they were suppose to do, there was no clear leadership, there was no announcement of which room had the simulated fire and staff had to be coached to activate the fire alarm pull station.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to install fire alarm system in accordance with NFPA 72 systems.
This resulted in the potential for delay and panic during fire emergencies (LSC 39.3.4, 39.3.4.2, 9.6, NFPA 72).
Findings include, but are not limited to:
1. On 7/8/2015, at 8:10 a.m., there were fire alarm pull stations within the Lake Health Clinic that were mounted approximately 63" and 62" from the finish floor which was more then the required height of 42" - 48" from finish floor.
Fire alarm pull stations were located within the north and south parts of the building.
2. On 7/8/2015, at 8:10 a.m., there were fire alarm pull stations within the Lake Health Clinics that were not installed within 5' of the egress door as required by NFPA 72.
Fire alarm pull station were located within the north and south parts of the building.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to test and maintain the fire alarm in accordance with NFPA 72.
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 7/8/2015, at 8:03 a.m., there was a blocked fire alarm pull station by a bed table adjacent to the south exit from the Sleep Lab area.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to test and maintain fire alarm in accordance with NFPA 72.
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 7/7/2015, during record review between 11:30 a.m. and 6:00 p.m., there was no documentation provided to the surveyor's showing monthly fire alarm inspection and maintenance by either Plant Operations Staff or a Third Party Vendor.
2. On 7/8/2015, at 11:30 a.m., the electrical breaker for the fire alarm sub-panel box located within the corridor outside of the Rural Health Clinic did not have a set screw lock on the electrical breaker (Panel H, breaker #19).
3. On 7/8/2015, at 2:24 p.m., during the fire drill, the surveyor noted that the fire alarm visual notification devices within the Rock Garden area and Scullery Hall adjacent to the Gift Shop were not synchronized.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13.
This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 39.3.2 NFPA 13 5-6.3.3, .4, NFPA 25).
Findings include, but are not limited to:
1. On 7/8/2015, at 7:45 a.m., there was missing required automatic sprinkler coverage in the exterior awning outside the main entrance of the Rural Health Building.
2. On 7/8/2015, at 7:45 a.m., there was missing required automatic sprinkler coverage within the covered entrance to the Rural Health Building.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations 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 7/8/2015, at 8:30 a.m., there was a missing spare stock of sidewall sprinkler heads within the spare sprinkler cabinet that served the sprinkler system for the Sleep Lab.
Facility was required to maintain a minimum of 6 spare heads or two of each type and temperature whichever was greater.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and 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 7/7/2015, during record review between 11:30 a.m. and 6:00 p.m., there was no documentation provided to the surveyor's showing weekly fire sprinkler inspection and maintenance by either Plant Operations Staff or a Third Party Vendor for March and April 2015.
2. On 7/7/2015, during record review between 11:30 a.m. and 6:00 p.m., there was no documentation provided to the surveyor's showing monthly fire sprinkler inspection and maintenance by either Plant Operations Staff or a Third Party Vendor for December 2014 and June 2015.
3. On 7/8/2015, at 9:30 a.m., there was insulation material dislodged from the above roof deck that was creating an obstruction to the automatic sprinkler head within the North Attic area.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to maintain or install 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 7/8/2015, at 9:50 a.m., there was not a minimum required 10A 120B sized fire extinguisher located at the facilities Helistop. The fire extinguisher located at the Helistop was a Purple K extinguisher.
2. On 7/8/2015, at 10:19 a.m., the fire extinguisher within the Laboratory Area was only a B, C rated fire extinguisher and not the minimum required 2A, 10B:C rated fire extinguisher.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to ensure that no combustibles or decorations of highly flammable character are used, or stored improperly within the building.
This resulted in the potential for excessive fire spread (LSC 39.3.2, 7.12, NEC 70).
Findings include, but are not limited to:
1. On 7/8/2015, at 8:12 a.m., there were combustible materials (cardboard boxes, paper products, etc.) stored within 24" of the ceiling throughout the unsprinklered Lake Health Clinic area including but not limited to Rm. 4 and the Record Storage Room.
2. On 7/8/2015, at 8:15 a.m., there were combustible materials (cardboard and paper) stacked and piled around the water heater within the Record Storage Room of Lake Health Clinic.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to provide safe storage for compressed gas cylinders in the facility.
This resulted in the potential for injury to staff and residents from a damaged compressed gas cylinder releasing unexpectedly. (LSC 39.3.2.4, NFPA 99 4.3.1.1.2).
Findings include, but are not limited to:
1. On 7/8/2015, at 8:02 a.m., there were 4-compressed gas cylinders that were not properly secured by evidence of the cylinders standing in a free non-restrained fashion that would allow the bottoms of the cylinders to kick out and strike other cylinders or walls within the Clean Room of the Sleep Lab during a seismic event.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to ensure that piped in medical gas systems comply with NFPA 99.
This resulted in the potential for injury to patients during medical procedures.
Findings include but are not limited to:
1. On 7/8/2015, at 7:52 a.m., there was warning/caution signage at the Liquid Oxygen Storage tank that was weathered and faded that shall be replaced.
Signage needs to meet the requirements of NFPA 99, 1999 edition, Section 4-3.1.1.7 and NFPA 50, 1996 edition, Section 3-5.8.

Based on record review and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1 (S&C 13-25 LSC)
This resulted in the potential for injury to patients during medical procedures.
Findings include, but are not limited to:
1. On 7/7/2015, during record review between at 11:30 a.m. and 6:00 p.m., the facility failed to provide Humidity monitoring logs for the anesthetizing locations for the hospital. Staff indicated that there were no Humidity Logs being kept and that the system was monitored by a computerized system.
A log of average OR Humidity, that was monitored by the HVAC system was provided and showed only 22 entries from 4/9/2014 to 7/7/2015. There were 16 entries that showed the humidity measured below 35% and 9 entries that showed the humidity measured below 30%.
Facility staff indicated that they did not have a humidity policy and provided a chart that outlines the humidity range that was monitored and the facility identified 30% relative humidity as their adopted range.
The facility also did not address what the facility would do or who the facility would notify when the humidity was not within the adopted acceptable range.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to maintain the installation of blanket warmers for the facility, complying with NFPA 99, 1999 ed. Section 9-2.1.8.1(l)

This resulted in the potential for unexpected ignition source & excessive fire spread.

Findings include, but are not limited to:

1. On 07/8/2015, between 8:36 and 9:46 a.m., there were combustible items stored on top of and against blanket warmers in the Acute Care Linen Room and ER Consultation Room.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to maintain the installation of the Liquid Propane Gas Vaporizer in accordance with NFPA 58, 2004 ed., Section 6.11.

This resulted in the potential for unexpected ignition of expanding liquid propane and failure of the gas piping system.

Findings include, but are not limited to:

2. On 07/08/2015 at 7:49 a.m., there was liquid piping to the electric LPG Vaporizer that could impound liquid propane between control valves without over pressurization protection from a hydrostatic relief valve.

Based on record review and interviews it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to properly maintain the generator for 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 7/7/2015, during record review between 11:30 a.m. and 6:00 p.m., there was no documentation provided to the surveyor's showing monthly emergency generator inspection and maintenance by either Plant Operations Staff or a Third Party Vendor for December 2014, March 2015, April 2015 and May 2015.
2. On 7/7/2015, during record review between 11:30 a.m. and 6:00 p.m., there was no documentation provided showing the required weekly electrolyte and monthly specific gravity testing on the emergency generator batteries.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and 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 residents & staff (NFPA 70, 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 7/8/2015, at 7:47 a.m., there were multiple open electrical junction boxes within the Chiller Room of the Facility CUP.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Plant Operations and Plant Operations Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70.
This resulted in the potential for injury to patients & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8).
Findings include, but are not limited to:
1. On 7/8/2015, at 8:02 a.m., there was compressed gas cylinders being stored within the Clean Room Storage closet within the Sleep Lab area that had electrical outlets/switches within 60" of the finish floor.
2. On 7/8/2015, at 8:20 a.m., there were multiple relocatable power taps (RPT's) on the floor within the Lake Health Clinic.
3. On 7/8/2015, at 8:25 a.m., there was a household grade microwave, toaster and coffee maker within the Staff Breakroom of the Lake Health Clinic.