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Based on observations and interviews it was determined that the facility failed to meet or maintain the construction type requirements. This resulted in the potential for fire/smoke to spread to other areas of the facility, causing the exposure of residents & staff to hazardous products of fire (LSC 18.3.6.1, .2, .5). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions: Findings include, but are not limited to:

1. On August 9, 2011 at 1:25 p.m., unsealed fire wall penetrations were found around the electrical conduit located in the Water Room next to the Plant Services Office.

Based on observations and interviews it was determined that the facility failed to meet or maintain the construction type requirements. This resulted in the potential for fire/smoke to spread to other areas of the facility, causing the exposure of residents & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:51 p.m., unsealed penetrations were found in the Laundry, Boiler Room, Maintenance Shop and Computer Room.

2. On August 9, 2011 at 3:01 p.m., unsealed ceiling penetrations were found in the Dry Storage Room.

3. On August 9, 2011 at 3:49 p.m., unsealed ceiling penetrations were found in the Medical Records Room next to the office.

Based on observations, record review and interviews it was determined that the facility failed to maintain exit corridor doors to resist the passage of smoke in accordance with NFPA 80. This resulted in the potential for 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, 4.6.12.1). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:02 p.m., the door for the Soiled Utility Room located across from Housekeeping Supplies did not close and latch.

2. On August 9, 2011 at 2:05 p.m., the door to Room 113 required force in excess of five-pounds to open.

3. On August 9, 2011 at 2:15 p.m., the small leaf to the door of Room 105 did not automatically close and latch.

4. On August 9, 2011 at 2:46 p.m., the fire doors next to Room 710 did not close and latch.

Based on observations, record review and interviews it was determined that the facility failed to maintain exit corridor doors to resist the passage of smoke in accordance with NFPA 80. This resulted in the potential for passage of smoke into the means of egress in the event of a hostile fire event (LSC 19.2.3.5, 19.3.6.3, 4.6.12.1). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 3:16 p.m., the door between the Cafeteria and corridor was propped open with a door chock.

Based on observations and interview it was determined that the facility failed to provide opening protection, which separates exit corridors from hazardous areas with a sprinkler and smoke partition in existing facilities (Ch. 19) or with a 3/4 hour rated door without windows in a new facility (Ch. 18). This resulted in the potential for the spread of fire/smoke into other portions of the facility including the means of egress during a hostile fire event (LSC 19.3.2.6, 8.2.3.2, 7.2.1.8, 19.3.2.1). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 4:18 p.m., resident room 319 was converted into a storage room and did not have a closer on the door.

Based on observations and interview it was determined that the facility failed to ensure there were no dead ends exceeding 30' in new buildings( Ch. 18). This resulted in the potential for panic and injury during emergency evacuations and relocation (LSC 7.1, 18.2.1, 18.2.5.10). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:30 p.m., the corridor leading from the Acute Care area to the Surgery Suite measured in excess of 30-feet.

Based on observations and interview it was determined that the facility failed to install/maintain exit access throughout the means of egress including the exterior to the public way or 50' from the building. (LSC 7.1, 18.2.1, 18.2.5.10). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:30 p.m., the door leading to the Labor and Delivery Department was marked as an exit and locked.

Based on observations and interview it was determined that the facility failed to provide adequate exit illumination to the public way with bulbs arranged so that if one bulb burned out there would still be adequate exit lighting. This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions (LSC 19.2.8). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 4:05 p.m., the light fixture outside of the entry to the Long Term Care area had only a single bulb.

2. On August 9, 2011 at 4:24 p.m., the exterior egress light fixture by Room 323 did not have two bulbs. Also, the exterior lights on the building did not run on emergency power to light an area at least 50-feet from the building or to a public way.

Based on observations, interviews and record review it was determined that the facility failed to maintain emergency action plan current & readily available. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 18.7.1.1). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 1:15 p.m., a review of the facility's disaster manual revealed the following deficiencies: Transfer and transportation agreements had not been reviewed on an annual basis, the facility did not have means of marking doors during relocation procedures, there was no hazard assessment included, there was no organization of the plan for quick reference, no floor plan of the building was included, there was no map of the utility shut-offs or smoke compartments included, the plan was dated August 4, 2008 and was incomplete, and there was no direction to notify the Office of State Fire Marshal if the facility experienced a fire or evacuation.

Based on observations, interviews and record review it was determined that the facility failed to maintain emergency action plan current & readily available. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 1:15 p.m., a review of the facility's disaster manual revealed the following deficiencies: Transfer and transportation agreements had not been reviewed on an annual basis, the facility did not have means of marking doors during relocation procedures, there was no hazard assessment included, there was no organization of the plan for quick reference, no floor plan of the building was included, there was no map of the utility shut-offs or smoke compartments included, the plan was dated August 4, 2008 and was incomplete, and there was no direction to notify the Office of State Fire Marshal if the facility experienced a fire or evacuation.

Based on record reviews and interviews it was determined that the facility failed to provide fire drills for all staff. 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). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 11:18 a.m., documentation was missing for the 2nd quarter day and night shift fire drills.

Based on record reviews and interviews it was determined that the facility failed to provide fire drills for all staff. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 11:20 a.m., documentation was missing for the 1st quarter night shift, 2nd quarter swing shift, and 4th quarter swing shift fire drills for the Long Term Care area of the facility

Based on observations, record review and interviews it was determined that the facility failed to install the fire alarm system in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 18.3.4, 9.6). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 1:34 p.m., the fire alarm control panel did not indicate the location of the electrical panel or the breaker for the system.

Based on observations and interview it was determined that the facility failed to ensure that there was complete sprinkler coverage in accordance with NFPA 13 for all portions of the building. This resulted in the potential for sprinkler failure and for uncontrolled fire progression in the event of a fire (LSC 19.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 3:29 p.m., the overhang located outside of the Maintenance Shop projected more than four-feet from the building, had a dumpster stored underneath and was not sprinklered.

Based on observations, record review and interviews it was determined that the facility failed to ensure that sprinkler system is 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 9.6.2.1, .2 & 8.17.4.6). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:00 p.m., the shower curtains located in patient rooms throughout the new hospital were found to be located within 18-inches of the fire sprinkler deflector. This finding was confirmed by interview with the Maintenance Director.

2. On August 9, 2011 at 2:37 p.m., a fire sprinkler head in the Soiled Utility Room in Labor and Delivery had a bent deflector.

Based on observations, record review and interviews it was determined that the facility failed to ensure that sprinkler system is 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 9.6.2.1, .2 & 8.17.4.6). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 3:01 p.m., storage was found within 18-inches of a fire sprinkler deflector and an escutcheon ring was missing in the Dry Storage Room and also the Medical Records Storage.

2. On August 9, 2011 at 4:20 p.m., fire sprinklers in Rooms 321, 322 and 323 had paint on them.

Based on observations and interview it was determined that the facility failed to maintain fire extinguishers. 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). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 1:23 p.m., fire extinguishers installed throughout the Central Utility Plant were mounted higher than 60-inches from the floor to the top of the handle.

Based on observations and interview it was determined that the facility failed to maintain fire extinguishers. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:51 p.m., the fire extinguisher was mounted over 60-inches from the floor to the handle in the Laundry, Boiler Room and Maintenance Shop.

2. On August 9, 2011 at 4:16 p.m., the fire extinguisher mounted in the corridor of the Long Term Care area was mounted over 60-inches from the floor to the handle.

3. On August 9, 2011 at 4:26 p.m., there was no fire extinguisher found in the Beauty Shop.

Based on observations and interview it was determined that the facility failed to install an approved ventilation hood and duct system. This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 4.6.12.1, 9.2.3, 19.3.2.6, NFPA 96 A.1.1.4, UL300). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 3:12 p.m., the filters serving the Kitchen Hood System were dirty.

2. On August 9, 2011 at 12:20 p.m., a report was reviewed that was written by a third-party contractor on April 27, 2011, stating that the Kitchen Hood Duct was " really greasy and dirty " . This condition was confirmed by the surveyor upon inspection of the duct exhaust from the roof of the facility.

Based upon observations and interviews it was determined that the facility failed to ensure that no furnishings or decorations of highly flammable character are used. This resulted in the potential for excessive fire spread (LSC 19.7.5.4). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 4:06 p.m., a decorative plant had foam in the base in the entryway of the Long Term Care area.

Based on observations, record review and interviews it was determined that the facility failed to provide safe storage for compressed gas (for light switch in oxygen storage room/ref. NFPA 99, A-4-3.1.1.2(a)2 #4). This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks (LSC 19.3.2.4, 4.3.1.1.2). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 4:13 p.m., the electrical outlets and light switch were within 60-inches of the floor in the Oxygen Storage Room.

Based on observations, record review and interviews it was determined that the facility failed to ensure that piped in medical gas systems comply with NFPA 99. This resulted in the potential for injury to bystanders near the storage area. Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include but are not limited to:

1. On August 9, 2011 at 1:15 p.m., the concrete curb near the liquid oxygen storage tank was installed with multiple gaps and was not continued onto the pad that the tank was installed on.

Based on observations, and interviews it was determined that the facility failed to store flammable & combustible liquids in an approved manner. This resulted in the potential for flammable fumes in uncontrolled areas (LSC 10.7.2.1, NFPA 99, NFPA 45, NFPA 30). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:57 p.m., cutting torch gases and other flammable and combustible liquids were stored in the Maintenance Shop.

Based on observations, record review and interviews it was determined that the facility failed to properly maintain the generator. 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) Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 4:57 p.m., the small generator's fuel tank was not vented at least 12-feet from grade, and there was no remote shut-off switch outside of the cabinet

Based on observations, record review and interviews it was determined that the facility failed to properly maintain the generator. 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). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 1:26 p.m., there was no battery-powered emergency light located in the Electrical Room.

Based on observations, record review and interviews it was determined that the facility failed to ensure that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to residents & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 10:23 a.m., a non-patient approved relocatable power tap was found on the floor at the O.R. Nursing Station.

2. On August 9, 2011 at 10:29 a.m., a 6 to 2 outlet plug adapter was found in Central Processing.

3. On August 9, 2011 at 1:24 p.m., two relocatable power taps were found in the Director of Plant Services office.

4. On August 9, 2011 at 1:46 p.m., relocatable power taps were found in Room 411, 403, the ED Nurse's Station, the control room and tech work areas for CT and Radiology, and the Radiology manager's desk.

5. On August 9, 2011 at 1:55 p.m., an unmaintained plug-in air freshener was found in the patient restroom of Ultrasound 501.

6. On August 9, 2011 at 1:56 p.m., a relocatable power tap was found at the Acute Care Nurse's Station.

7. On August 9, 2011 at 2:43 p.m., two relocatable power taps were found in the Lab and one in the Cardio Pulmonary Manager's Office.

Based on observations, record review and interviews it was determined that the facility failed to ensure that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to residents & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:55 p.m., two relocatable power taps were found in the Maintenance Shop. Multiple relocatable power taps were also located in the Computer Room.

2. On August 9, 2011 at 3:05 p.m., relocatable power taps were found in the Accounts Payable and Purchasing/Supply Offices.

3. On August 9, 2011 at 3:13 p.m., extension cords and relocatable power taps were found in the Kitchen and Cafeteria. An air conditioner was plugged into one of the power taps and a coffee maker into another

4. On August 9, 2011 at 3:39 p.m., vending machines near the Lobby were plugged into a relocatable power tap and the cords were run through a wall.

5. On August 9, 2011 at 3:49 p.m., a relocatable power tap was found plugged into an uninterruptible power supply, and two other relocatable power taps were found in the Medical Records Office.

6. On August 9, 2011 at 3:50 p.m., a relocatable power tap and broken electrical outlet were found in the Executive Assistant's Office. Relocatable power taps were also found in the CFO and COO Offices.

7. On August 9, 2011 at 4:01 p.m., a relocatable power tap was found at the fish tank in the entryway of the Long Term Care area.

8. On August 9, 2011 at 4:07 p.m., relocatable power taps were found in the DNS Office, at the Nurse's Station and in the Nursing Office.

9. On August 9, 2011 at 4:08 p.m., a microwave was found to be accessible to the residents in the Long Term Care Pantry.

10. On August 9, 2011 at 4:17 p.m., a household-rated coffee pot and relocatable power tap were found in the Office marked 317.

11. On August 9, 2011 at 4:21 p.m., a relocatable power tap was found in Room 323.

12. On August 9, 2011 at 4:26 p.m., the electrical outlet located behind the hair dryer was within six-feet of the sink and was not GFCI-rated.

13. On August 9, 2011 at 4:29 p.m., a relocatable power tap was found in Room 322.

Based on observations and interviews it was determined that the facility failed to install alcohol gel hand sanitizing dispensing stations away from sources of ignition and a minimum of 4' spacing between dispensers. This resulted in the potential for injury to residents and staff (CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 11:27 a.m., an alcohol hand gel dispenser was mounted above the light switch in the Accounting Conference Room.

2. On August 9, 2011 at 3:15 p.m., an alcohol hand gel dispenser was mounted above the light switch in the Cafeteria.

Based on observations and interviews it was determined that the facility failed to install alcohol gel hand sanitizing dispensing stations away from sources of ignition and a minimum of 4' spacing between dispensers. This resulted in the potential for injury to residents and staff (LSC 18.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:34 p.m., an alcohol hand sanitizer dispenser was mounted above the light switch at the Labor and Delivery Nurse's Station.

Based on observations and interviews it was determined that the facility failed to meet or maintain the construction type requirements. This resulted in the potential for fire/smoke to spread to other areas of the facility, causing the exposure of residents & staff to hazardous products of fire (LSC 18.3.6.1, .2, .5). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions: Findings include, but are not limited to:

1. On August 9, 2011 at 1:25 p.m., unsealed fire wall penetrations were found around the electrical conduit located in the Water Room next to the Plant Services Office.

Based on observations and interviews it was determined that the facility failed to meet or maintain the construction type requirements. This resulted in the potential for fire/smoke to spread to other areas of the facility, causing the exposure of residents & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:51 p.m., unsealed penetrations were found in the Laundry, Boiler Room, Maintenance Shop and Computer Room.

2. On August 9, 2011 at 3:01 p.m., unsealed ceiling penetrations were found in the Dry Storage Room.

3. On August 9, 2011 at 3:49 p.m., unsealed ceiling penetrations were found in the Medical Records Room next to the office.

Based on observations, record review and interviews it was determined that the facility failed to maintain exit corridor doors to resist the passage of smoke in accordance with NFPA 80. This resulted in the potential for 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, 4.6.12.1). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:02 p.m., the door for the Soiled Utility Room located across from Housekeeping Supplies did not close and latch.

2. On August 9, 2011 at 2:05 p.m., the door to Room 113 required force in excess of five-pounds to open.

3. On August 9, 2011 at 2:15 p.m., the small leaf to the door of Room 105 did not automatically close and latch.

4. On August 9, 2011 at 2:46 p.m., the fire doors next to Room 710 did not close and latch.

Based on observations, record review and interviews it was determined that the facility failed to maintain exit corridor doors to resist the passage of smoke in accordance with NFPA 80. This resulted in the potential for passage of smoke into the means of egress in the event of a hostile fire event (LSC 19.2.3.5, 19.3.6.3, 4.6.12.1). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 3:16 p.m., the door between the Cafeteria and corridor was propped open with a door chock.

Based on observations and interview it was determined that the facility failed to provide opening protection, which separates exit corridors from hazardous areas with a sprinkler and smoke partition in existing facilities (Ch. 19) or with a 3/4 hour rated door without windows in a new facility (Ch. 18). This resulted in the potential for the spread of fire/smoke into other portions of the facility including the means of egress during a hostile fire event (LSC 19.3.2.6, 8.2.3.2, 7.2.1.8, 19.3.2.1). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 4:18 p.m., resident room 319 was converted into a storage room and did not have a closer on the door.

Based on observations and interview it was determined that the facility failed to ensure there were no dead ends exceeding 30' in new buildings( Ch. 18). This resulted in the potential for panic and injury during emergency evacuations and relocation (LSC 7.1, 18.2.1, 18.2.5.10). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:30 p.m., the corridor leading from the Acute Care area to the Surgery Suite measured in excess of 30-feet.

Based on observations and interview it was determined that the facility failed to install/maintain exit access throughout the means of egress including the exterior to the public way or 50' from the building. (LSC 7.1, 18.2.1, 18.2.5.10). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:30 p.m., the door leading to the Labor and Delivery Department was marked as an exit and locked.

Based on observations and interview it was determined that the facility failed to provide adequate exit illumination to the public way with bulbs arranged so that if one bulb burned out there would still be adequate exit lighting. This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions (LSC 19.2.8). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 4:05 p.m., the light fixture outside of the entry to the Long Term Care area had only a single bulb.

2. On August 9, 2011 at 4:24 p.m., the exterior egress light fixture by Room 323 did not have two bulbs. Also, the exterior lights on the building did not run on emergency power to light an area at least 50-feet from the building or to a public way.

Based on observations, interviews and record review it was determined that the facility failed to maintain emergency action plan current & readily available. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 18.7.1.1). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 1:15 p.m., a review of the facility's disaster manual revealed the following deficiencies: Transfer and transportation agreements had not been reviewed on an annual basis, the facility did not have means of marking doors during relocation procedures, there was no hazard assessment included, there was no organization of the plan for quick reference, no floor plan of the building was included, there was no map of the utility shut-offs or smoke compartments included, the plan was dated August 4, 2008 and was incomplete, and there was no direction to notify the Office of State Fire Marshal if the facility experienced a fire or evacuation.

Based on observations, interviews and record review it was determined that the facility failed to maintain emergency action plan current & readily available. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 1:15 p.m., a review of the facility's disaster manual revealed the following deficiencies: Transfer and transportation agreements had not been reviewed on an annual basis, the facility did not have means of marking doors during relocation procedures, there was no hazard assessment included, there was no organization of the plan for quick reference, no floor plan of the building was included, there was no map of the utility shut-offs or smoke compartments included, the plan was dated August 4, 2008 and was incomplete, and there was no direction to notify the Office of State Fire Marshal if the facility experienced a fire or evacuation.

Based on record reviews and interviews it was determined that the facility failed to provide fire drills for all staff. 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). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 11:18 a.m., documentation was missing for the 2nd quarter day and night shift fire drills.

Based on record reviews and interviews it was determined that the facility failed to provide fire drills for all staff. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 11:20 a.m., documentation was missing for the 1st quarter night shift, 2nd quarter swing shift, and 4th quarter swing shift fire drills for the Long Term Care area of the facility

Based on observations, record review and interviews it was determined that the facility failed to install the fire alarm system in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 18.3.4, 9.6). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 1:34 p.m., the fire alarm control panel did not indicate the location of the electrical panel or the breaker for the system.

Based on observations and interview it was determined that the facility failed to ensure that there was complete sprinkler coverage in accordance with NFPA 13 for all portions of the building. This resulted in the potential for sprinkler failure and for uncontrolled fire progression in the event of a fire (LSC 19.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 3:29 p.m., the overhang located outside of the Maintenance Shop projected more than four-feet from the building, had a dumpster stored underneath and was not sprinklered.

Based on observations, record review and interviews it was determined that the facility failed to ensure that sprinkler system is 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 9.6.2.1, .2 & 8.17.4.6). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:00 p.m., the shower curtains located in patient rooms throughout the new hospital were found to be located within 18-inches of the fire sprinkler deflector. This finding was confirmed by interview with the Maintenance Director.

2. On August 9, 2011 at 2:37 p.m., a fire sprinkler head in the Soiled Utility Room in Labor and Delivery had a bent deflector.

Based on observations, record review and interviews it was determined that the facility failed to ensure that sprinkler system is 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 9.6.2.1, .2 & 8.17.4.6). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 3:01 p.m., storage was found within 18-inches of a fire sprinkler deflector and an escutcheon ring was missing in the Dry Storage Room and also the Medical Records Storage.

2. On August 9, 2011 at 4:20 p.m., fire sprinklers in Rooms 321, 322 and 323 had paint on them.

Based on observations and interview it was determined that the facility failed to maintain fire extinguishers. 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). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 1:23 p.m., fire extinguishers installed throughout the Central Utility Plant were mounted higher than 60-inches from the floor to the top of the handle.

Based on observations and interview it was determined that the facility failed to maintain fire extinguishers. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:51 p.m., the fire extinguisher was mounted over 60-inches from the floor to the handle in the Laundry, Boiler Room and Maintenance Shop.

2. On August 9, 2011 at 4:16 p.m., the fire extinguisher mounted in the corridor of the Long Term Care area was mounted over 60-inches from the floor to the handle.

3. On August 9, 2011 at 4:26 p.m., there was no fire extinguisher found in the Beauty Shop.

Based on observations and interview it was determined that the facility failed to install an approved ventilation hood and duct system. This resulted in the potential for fire spread due to inappropriate and/or inadequate fire protection (LSC 4.6.12.1, 9.2.3, 19.3.2.6, NFPA 96 A.1.1.4, UL300). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 3:12 p.m., the filters serving the Kitchen Hood System were dirty.

2. On August 9, 2011 at 12:20 p.m., a report was reviewed that was written by a third-party contractor on April 27, 2011, stating that the Kitchen Hood Duct was " really greasy and dirty " . This condition was confirmed by the surveyor upon inspection of the duct exhaust from the roof of the facility.

Based upon observations and interviews it was determined that the facility failed to ensure that no furnishings or decorations of highly flammable character are used. This resulted in the potential for excessive fire spread (LSC 19.7.5.4). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 4:06 p.m., a decorative plant had foam in the base in the entryway of the Long Term Care area.

Based on observations, record review and interviews it was determined that the facility failed to provide safe storage for compressed gas (for light switch in oxygen storage room/ref. NFPA 99, A-4-3.1.1.2(a)2 #4). This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks (LSC 19.3.2.4, 4.3.1.1.2). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 4:13 p.m., the electrical outlets and light switch were within 60-inches of the floor in the Oxygen Storage Room.

Based on observations, record review and interviews it was determined that the facility failed to ensure that piped in medical gas systems comply with NFPA 99. This resulted in the potential for injury to bystanders near the storage area. Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include but are not limited to:

1. On August 9, 2011 at 1:15 p.m., the concrete curb near the liquid oxygen storage tank was installed with multiple gaps and was not continued onto the pad that the tank was installed on.

Based on observations, and interviews it was determined that the facility failed to store flammable & combustible liquids in an approved manner. This resulted in the potential for flammable fumes in uncontrolled areas (LSC 10.7.2.1, NFPA 99, NFPA 45, NFPA 30). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:57 p.m., cutting torch gases and other flammable and combustible liquids were stored in the Maintenance Shop.

Based on observations, record review and interviews it was determined that the facility failed to properly maintain the generator. 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) Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 4:57 p.m., the small generator's fuel tank was not vented at least 12-feet from grade, and there was no remote shut-off switch outside of the cabinet

Based on observations, record review and interviews it was determined that the facility failed to properly maintain the generator. 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). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 1:26 p.m., there was no battery-powered emergency light located in the Electrical Room.

Based on observations, record review and interviews it was determined that the facility failed to ensure that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to residents & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 10:23 a.m., a non-patient approved relocatable power tap was found on the floor at the O.R. Nursing Station.

2. On August 9, 2011 at 10:29 a.m., a 6 to 2 outlet plug adapter was found in Central Processing.

3. On August 9, 2011 at 1:24 p.m., two relocatable power taps were found in the Director of Plant Services office.

4. On August 9, 2011 at 1:46 p.m., relocatable power taps were found in Room 411, 403, the ED Nurse's Station, the control room and tech work areas for CT and Radiology, and the Radiology manager's desk.

5. On August 9, 2011 at 1:55 p.m., an unmaintained plug-in air freshener was found in the patient restroom of Ultrasound 501.

6. On August 9, 2011 at 1:56 p.m., a relocatable power tap was found at the Acute Care Nurse's Station.

7. On August 9, 2011 at 2:43 p.m., two relocatable power taps were found in the Lab and one in the Cardio Pulmonary Manager's Office.

Based on observations, record review and interviews it was determined that the facility failed to ensure that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to residents & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Surveyors were accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On August 9, 2011 at 2:55 p.m., two relocatable power taps were found in the Maintenance Shop. Multiple relocatable power taps were also located in the Computer Room.

2. On August 9, 2011 at 3:05 p.m., relocatable power taps were found in the Accounts Payable and Purchasing/Supply Offices.

3. On August 9, 2011 at 3:13 p.m., extension cords and relocatable power taps were found in the Kitchen and Cafeteria. An air conditioner was plugged into one of the power taps and a coffee maker into another

4. On August 9, 2011 at 3:39 p.m., vending machines near the Lobby were plugged into a relocatable power tap and the cords were run through a wall.

5. On August 9, 2011 at 3:49 p.m., a relocatable power tap was found plugged into an uninterruptible power supply, and two other relocatable power taps were found in the Medical Records Office.

6. On August 9, 2011 at 3:50 p.m., a relocatable power tap and broken electrical outlet were found in the Executive Assistant's Office. Relocatable power taps were also found in the CFO and COO Offices.

7. On August 9, 2011 at 4:01 p.m., a relocatable power tap was found at the fish tank in the entryway of the Long Term Care area.

8. On August 9, 2011 at 4:07 p.m., relocatable power taps were found in the DNS Office, at the Nurse's Station and in the Nursing Office.

9. On August 9, 2011 at 4:08 p.m., a microwave was found to be accessible to the residents in the Long Term Care Pantry.

10. On August 9, 2011 at 4:17 p.m., a household-rated coffee pot and relocatable power tap were found in the Office marked 317.

11. On August 9, 2011 at 4:21 p.m., a relocatable power tap was found in Room 323.

12. On August 9, 2011 at 4:26 p.m., the electrical outlet located behind the hair dryer was within six-feet of the sink and was not GFCI-rated.

13. On August 9, 2011 at 4:29 p.m., a relocatable power tap was found in Room 322.