HospitalInspections.org

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to separate sections of health care facilities from non-healthcare facilities. This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 19.1.2.3, 19.1.1.4, 19.1.2.3). Findings include, but are not limited to:
1. On 5/4/2016, at 1:30 p.m., there were penetrations within the 2-hr wall between the Administration Wing and the Main Hospital. Penetrations where approximately 3/4" in diameter and a horizontal seem between the gypsum board that measured approximately 8' - 10' long. The penetration was adjacent to the Pharmacy.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities 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 attic spaces in the event of a fire, causing the exposure of patients & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Findings include, but are not limited to:
1. On 5/4/2016, at 4:02 p.m., there was a horizontal seem that was not finished completely that was part of the 2-hr. wall between the attached Clinic Building and Hospital. The unfinished seem was located above the door in the back hallway of the Clinic Building.
2. On 5/4/2016, at 4:04 p.m., there was a horizontal seem that was not finished completely that was part of the 2-hr. wall between the attached Clinic Building and Hospital. The unfinished seem was located above the door between the Clinic Building and Hospital adjacent to the Main Hospital Entrance.
3. On 5/5/2016, at 11:37 a.m., there was a ceiling penetration that measured approximately 4" in diameter within Rm. #2224. This penetration was in the ceiling hard lid and would allow products of combustion (heat and smoke) into the attic/concealed space of the building.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities 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 19.2.3.5, Table 19.3.2.1, 19.3.6.3, Exception 2; A19.3.6.3.3). Findings include, but are not limited to:
1. On 5/4/2016, at 3:34 p.m., the north leaf of the cross-corridor doors within the 2-hr. wall on the 2nd floor between the old Extended Care Unit and the hospital was not closing and latching properly when tested by the surveyor.
2. On 5/4/2016, at 3:45 p.m., there was a unsealed 4" conduit penetration through the smoke barrier above cross-corridor doors 2C88A. The conduit was missing fire rated pillow.
3. On 5/4/2016, at 3:55 p.m., there was a unsealed conduit penetration through the smoke barrier above cross-corridor doors between the PACU and Emergency Department.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to provide a one hour separation between hazardous areas and the corridor. This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 38.3.2). Findings include, but are not limited to:
1. On 5/6/2016, at 1:56 p.m., there was a missing automatic door closure on the Soiled Utility Room across from Exam #5 within the Gearhart Clinic Space.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to provide a one hour separation between hazardous areas and the corridors of the building. This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 39.3.2, 8.4). Findings include, but are not limited to:
1. On 5/5/2016, at 11:28 a.m., there was a missing automatic door closure on the door of the Soiled Laundry Room within the Clinic Space.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities 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 19.7.1.2, A.19.7.1.2). Findings include, but are not limited to:
1. On 5/3/2016, during record review between 10:45 a.m. and 5:30 p.m., the facility had no documentation on conducting their 1st quarter night shift fire drill, and 3rd quarter night shift fire drill for 2015 and their 1st quarter night shift fire drill, and 3rd quarter night shift fire drill for 2014.
2. On 5/3/2016, during record review between 10:45 a.m. and 5:30 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as but not limited to the number of simulated occupants evacuated from the affected smoke compartment, time to complete the simulated evacuation from the affected smoke compartment to an unaffected smoke compartment, specific type of fire simulated, specific location of simulated fire and Staff Performance during the drill.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13 for the building. This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 18.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. On 5/5/2016, at 11:22 a.m., there was missing automatic sprinkler coverage within a electrical/communications closet behind Door #2C87C.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities 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 5/3/2016, at 2:20 p.m., there were multiple painted automatic sprinkler heads within OR #2 that shall be replaced.
2. On 5/4/2016, at 1:53 p.m., there was a damaged automatic sprinkler head adjacent to Door #1203, that shall be replaced.
3. On 5/4/2016, at 2:45 p.m., there were multiple corroded automatic sprinkler heads that protected the Facility Loading Dock, that shall be replaced.
4. On 5/5/2016, at 11:17 a.m., there was a corroded automatic sprinkler head on the 2nd floor adjacent to the Chapel and Men's bathroom that shall be replaced.
5. On 5/5/2016, at 11:23 a.m., there was a damaged automatic sprinkler head within OB Rm. #201 that shall be replaced.
6. On 5/5/2016, at 11:49 a.m., there was a damaged automatic sprinkler head within the Pharmacy.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to maintain fire extinguishers in accordance with adopted standards for extinguishers of the facility. 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). Findings include, but are not limited to:
1. On 5/4/2016, at 3:22 p.m., there was not a minimum 10A 120B fire extinguisher provided for the landing and take-off area of the Heliport. Facility only had a 4A 80B:C sized fire extinguisher for the Heliport.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10, S&C). Findings include, but are not limited to:
1. On 5/5/2016, during the facility tour between 9:00 a.m. 3:00 p.m., there were wall mounted computer terminals within the egress corridors that did not retract to the full closed position when opened and tested by the surveyor. Computer terminals were found to be outside of Patient Rm's. #204 and #211.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interviews it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to provide safe storage for compressed gas. This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks. (LSC 19.3.2.4, NFPA 99 4.3.1.1.2). Findings include, but were not limited to:
1. On 5/4/2016, at 2:46 p.m., there was electrical outlets and switches within 60" of the finish floor within the Exterior Oxygen Storage Room adjacent to the facilities Loading Dock.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1. This resulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to:
1. On 5/5/2016, during record review between 12:30 p.m. and 1:00 p.m., the humidity policy dated for 2015 that was presented to the surveyor had specified a humidity range to be maintained between 20% and 60%. Policy indicates that the Unit Manager will be notified if Engineering was unable to restore the humidity levels to the defined range within 30 minutes and to be aware of increased risk of fire caused by electrostatic discharges and to take appropriate precautions. The Policy does not outline what those appropriate precautions would be. Facility staff were unable to provide any Manufacturer's Instructions for Use (FU) to show that equipment within the anesthetizing locations could tolerate and work properly within the lower humidity levels.
2. On 5/5/2016, during record review between 12:30 p.m. and 1:00 p.m., the facility was unable to provide Humidity Logs for anesthetizing locations for the calendar year of 2014.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to properly maintain the generator affecting the entire facility. This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2). Findings include, but are not limited to:
1. On 5/3/2016, during record review between 10:45 a.m. and 5:30 p.m., the facilities required 3-yr. 4-hr. load bank test was incomplete and did not meet NFPA 110 standards. The load bank test was not conducted at a minimum of 80% of the generator nameplate.
2. On 5/4/2016, at 11:57 a.m., there was no 90-minute automatic task illumination on battery backup for the generator transfer switch room (Door 1M07).
3. On 5/5/2016, at 10:46 a.m., there was no 90-minute automatic task illumination on battery backup for the Clinic generator and ATS. The Clinic generator and ATS provide emergency power for spaces that were used within the Clinic by Hospital patients.
4. On 5/5/2016, at 10:46 a.m., the Clinic generator did not have an emergency stop button installed outside of the generators enclosure. The Clinic generator provides emergency power for spaces that were used within the Clinic by Hospital patients.
5. On 5/5/2016, at 10:46 a.m., the Clinic generator did not have a fuel vent that terminated a minimum of 12' above finish grade. The Clinic generator provides emergency power for spaces that were used within the Clinic by Hospital patients.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to provide an alternate source of power in accordance with NFPA 99 3.6, which would provide a minimum of 90 minutes of power in an outage. This resulted in the potential for panic and confusion for staff and residents in a power outage. Findings include, but are not limited to:
1. On 5/4/2016, during record review between 9:00 a.m. and 1:00 p.m., there was no documentation showing the required annual 90 minute test on emergency lights within the generator enclosure or generator transfer switch.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities 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 5/4/2016, at 2:40 p.m., there was a relocatable power tap that was permanently attached to the building wall next to the desk within the Laundry Room off the building. Power tap would require a special tool to remove.
2. On 5/4/2016, at 2:41 p.m., the laundry detergent dispensing machine was plugged/powered by a relocatable power tap instead of the dispensing machine plugged directly into a electrical wall socket.
3. On 5/4/2016,at 2:44 p.m., there were relocatable power taps that were permanently attached to the building wall within the Materials Receiving Room. Power taps would require a special tool to remove.
4. On 5/5/2016, at 10:24 a.m., there was a 3:1 cube adapter that was in use within the Finance Office.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities 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 5/5/2016, at 1:53 p.m., there were (2)relocatable power taps (RPT's) that were connected together in sequence (daisy chained) within the Home Health Office that was a part of the Gearhart Clinic.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on the observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to install alcohol based hand rub (ABHR) dispensers away from sources of ignition for the building. This resulted in the potential for injury to residents and staff (LSC 19.3.2.6, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 486.623, 485.623). Findings include, but are not limited to:
1. On 5/3/2016, at 2:15 p.m., there was an alcohol based hand rub (ABHR) dispenser installed above an electrical outlet outside of OR #1.
2. On 5/4/2016, at 4:23 p.m., there was an alcohol based hand rub (ABHR) dispenser installed above an electrical outlet in the corridor outside of ED Rm. #5, adjacent to Door #2408.
3. On 5/4/2016, at 4:35 p.m., there was an alcohol based hand rub (ABHR) dispenser installed above an electrical outlet adjacent to Door #2416.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to separate sections of health care facilities from non-healthcare facilities. This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 19.1.2.3, 19.1.1.4, 19.1.2.3). Findings include, but are not limited to:
1. On 5/4/2016, at 1:30 p.m., there were penetrations within the 2-hr wall between the Administration Wing and the Main Hospital. Penetrations where approximately 3/4" in diameter and a horizontal seem between the gypsum board that measured approximately 8' - 10' long. The penetration was adjacent to the Pharmacy.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities 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 attic spaces in the event of a fire, causing the exposure of patients & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Findings include, but are not limited to:
1. On 5/4/2016, at 4:02 p.m., there was a horizontal seem that was not finished completely that was part of the 2-hr. wall between the attached Clinic Building and Hospital. The unfinished seem was located above the door in the back hallway of the Clinic Building.
2. On 5/4/2016, at 4:04 p.m., there was a horizontal seem that was not finished completely that was part of the 2-hr. wall between the attached Clinic Building and Hospital. The unfinished seem was located above the door between the Clinic Building and Hospital adjacent to the Main Hospital Entrance.
3. On 5/5/2016, at 11:37 a.m., there was a ceiling penetration that measured approximately 4" in diameter within Rm. #2224. This penetration was in the ceiling hard lid and would allow products of combustion (heat and smoke) into the attic/concealed space of the building.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities 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 19.2.3.5, Table 19.3.2.1, 19.3.6.3, Exception 2; A19.3.6.3.3). Findings include, but are not limited to:
1. On 5/4/2016, at 3:34 p.m., the north leaf of the cross-corridor doors within the 2-hr. wall on the 2nd floor between the old Extended Care Unit and the hospital was not closing and latching properly when tested by the surveyor.
2. On 5/4/2016, at 3:45 p.m., there was a unsealed 4" conduit penetration through the smoke barrier above cross-corridor doors 2C88A. The conduit was missing fire rated pillow.
3. On 5/4/2016, at 3:55 p.m., there was a unsealed conduit penetration through the smoke barrier above cross-corridor doors between the PACU and Emergency Department.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to provide a one hour separation between hazardous areas and the corridor. This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 38.3.2). Findings include, but are not limited to:
1. On 5/6/2016, at 1:56 p.m., there was a missing automatic door closure on the Soiled Utility Room across from Exam #5 within the Gearhart Clinic Space.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to provide a one hour separation between hazardous areas and the corridors of the building. This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 39.3.2, 8.4). Findings include, but are not limited to:
1. On 5/5/2016, at 11:28 a.m., there was a missing automatic door closure on the door of the Soiled Laundry Room within the Clinic Space.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities 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 19.7.1.2, A.19.7.1.2). Findings include, but are not limited to:
1. On 5/3/2016, during record review between 10:45 a.m. and 5:30 p.m., the facility had no documentation on conducting their 1st quarter night shift fire drill, and 3rd quarter night shift fire drill for 2015 and their 1st quarter night shift fire drill, and 3rd quarter night shift fire drill for 2014.
2. On 5/3/2016, during record review between 10:45 a.m. and 5:30 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as but not limited to the number of simulated occupants evacuated from the affected smoke compartment, time to complete the simulated evacuation from the affected smoke compartment to an unaffected smoke compartment, specific type of fire simulated, specific location of simulated fire and Staff Performance during the drill.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13 for the building. This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 18.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. On 5/5/2016, at 11:22 a.m., there was missing automatic sprinkler coverage within a electrical/communications closet behind Door #2C87C.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities 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 5/3/2016, at 2:20 p.m., there were multiple painted automatic sprinkler heads within OR #2 that shall be replaced.
2. On 5/4/2016, at 1:53 p.m., there was a damaged automatic sprinkler head adjacent to Door #1203, that shall be replaced.
3. On 5/4/2016, at 2:45 p.m., there were multiple corroded automatic sprinkler heads that protected the Facility Loading Dock, that shall be replaced.
4. On 5/5/2016, at 11:17 a.m., there was a corroded automatic sprinkler head on the 2nd floor adjacent to the Chapel and Men's bathroom that shall be replaced.
5. On 5/5/2016, at 11:23 a.m., there was a damaged automatic sprinkler head within OB Rm. #201 that shall be replaced.
6. On 5/5/2016, at 11:49 a.m., there was a damaged automatic sprinkler head within the Pharmacy.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to maintain fire extinguishers in accordance with adopted standards for extinguishers of the facility. 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). Findings include, but are not limited to:
1. On 5/4/2016, at 3:22 p.m., there was not a minimum 10A 120B fire extinguisher provided for the landing and take-off area of the Heliport. Facility only had a 4A 80B:C sized fire extinguisher for the Heliport.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10, S&C). Findings include, but are not limited to:
1. On 5/5/2016, during the facility tour between 9:00 a.m. 3:00 p.m., there were wall mounted computer terminals within the egress corridors that did not retract to the full closed position when opened and tested by the surveyor. Computer terminals were found to be outside of Patient Rm's. #204 and #211.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interviews it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to provide safe storage for compressed gas. This resulted in the potential for damage to electrical switches and receptacles during the movement of oxygen tanks. (LSC 19.3.2.4, NFPA 99 4.3.1.1.2). Findings include, but were not limited to:
1. On 5/4/2016, at 2:46 p.m., there was electrical outlets and switches within 60" of the finish floor within the Exterior Oxygen Storage Room adjacent to the facilities Loading Dock.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1. This resulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to:
1. On 5/5/2016, during record review between 12:30 p.m. and 1:00 p.m., the humidity policy dated for 2015 that was presented to the surveyor had specified a humidity range to be maintained between 20% and 60%. Policy indicates that the Unit Manager will be notified if Engineering was unable to restore the humidity levels to the defined range within 30 minutes and to be aware of increased risk of fire caused by electrostatic discharges and to take appropriate precautions. The Policy does not outline what those appropriate precautions would be. Facility staff were unable to provide any Manufacturer's Instructions for Use (FU) to show that equipment within the anesthetizing locations could tolerate and work properly within the lower humidity levels.
2. On 5/5/2016, during record review between 12:30 p.m. and 1:00 p.m., the facility was unable to provide Humidity Logs for anesthetizing locations for the calendar year of 2014.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to properly maintain the generator affecting the entire facility. This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2). Findings include, but are not limited to:
1. On 5/3/2016, during record review between 10:45 a.m. and 5:30 p.m., the facilities required 3-yr. 4-hr. load bank test was incomplete and did not meet NFPA 110 standards. The load bank test was not conducted at a minimum of 80% of the generator nameplate.
2. On 5/4/2016, at 11:57 a.m., there was no 90-minute automatic task illumination on battery backup for the generator transfer switch room (Door 1M07).
3. On 5/5/2016, at 10:46 a.m., there was no 90-minute automatic task illumination on battery backup for the Clinic generator and ATS. The Clinic generator and ATS provide emergency power for spaces that were used within the Clinic by Hospital patients.
4. On 5/5/2016, at 10:46 a.m., the Clinic generator did not have an emergency stop button installed outside of the generators enclosure. The Clinic generator provides emergency power for spaces that were used within the Clinic by Hospital patients.
5. On 5/5/2016, at 10:46 a.m., the Clinic generator did not have a fuel vent that terminated a minimum of 12' above finish grade. The Clinic generator provides emergency power for spaces that were used within the Clinic by Hospital patients.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities Staff that the facility failed to provide an alternate source of power in accordance with NFPA 99 3.6, which would provide a minimum of 90 minutes of power in an outage. This resulted in the potential for panic and confusion for staff and residents in a power outage. Findings include, but are not limited to:
1. On 5/4/2016, during record review between 9:00 a.m. and 1:00 p.m., there was no documentation showing the required annual 90 minute test on emergency lights within the generator enclosure or generator transfer switch.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities 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 5/4/2016, at 2:40 p.m., there was a relocatable power tap that was permanently attached to the building wall next to the desk within the Laundry Room off the building. Power tap would require a special tool to remove.
2. On 5/4/2016, at 2:41 p.m., the laundry detergent dispensing machine was plugged/powered by a relocatable power tap instead of the dispensing machine plugged directly into a electrical wall socket.
3. On 5/4/2016,at 2:44 p.m., there were relocatable power taps that were permanently attached to the building wall within the Materials Receiving Room. Power taps would require a special tool to remove.
4. On 5/5/2016, at 10:24 a.m., there was a 3:1 cube adapter that was in use within the Finance Office.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Regional Facilities Director and Facilities 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 5/5/2016, at 1:53 p.m., there were (2)relocatable power taps (RPT's) that were connected together in sequence (daisy chained) within the Home Health Office that was a part of the Gearhart Clinic.
Surveyor was accompanied by the Regional Facilities Director and Facilities Staff who acknowledged the existence of these conditions.