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Based on observations and interview it was determined 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). Findings include, but are not limited to:

1. On June 28, 2011 at 11:44 a.m., the doors from the Nurse's Station to the Administration area did not provide proper smoke separation.

2. On June 28, 2011 at 11:45 a.m., the facility was not separated into two smoke compartments.

3. On June 28, 2011 at 12:24 p.m., the fire wall was found to be unfinished between the OB hallway and the Nursing Administrator's office.

4. On June 28, 2011 at 12:28 p.m., there was no smoke separation found between the Operating Room and the OB corridor.

5. On June 28, 2011 at 12:32 p.m., there was no smoke separation found between the OB corridor and the Surgical Services corridor.

6. On June 28, 2011 at 12:35 p.m., the doors between the Emergency Department and the Surgery corridor were not rated for smoke separation.

7. On June 28, 2011 at 12:38 p.m., there was no smoke separation between the Operating Room corridor and the Radiology corridor.

8. On June 28, 2011 at 12:47 p.m., unsealed ceiling penetrations were found throughout the Patient Rooms. Per interview with the Maintenance Supervisor, this condition existed throughout the patient wing as smoke detectors were relocated.

9. On June 28, 2011 at 12:49 p.m., an unsealed ceiling penetration was found in the Materials Management 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). Findings include, but are not limited to:

1. On June 28, 2011 at 11:44 a.m., the facility was not able to provide fire and life safety plans for the building to confirm the location of fire and smoke separations.

2. On June 28, 2011 at 12:16 p.m., unsealed penetrations were found in the two-hour fire wall between the CT corridor and the Purchasing office.

3. On June 28, 2011 at 12:40 p.m., unsealed wall penetrations were found in the Ultrasound Room.

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). Findings include, but are not limited to:

1. On June 28, 2011 at 10:45 a.m., maintenance forms for weekly, monthly and quarterly inspections of the fire and smoke doors were outdated and not in accordance with adopted standards, nor did the facility have access to NFPA 80, 1999 Edition in order to inspect, maintain, & test doors.

2. On June 28, 2011 at 10:45 a.m., the facility was missing documentation of maintenance on the smoke and fire doors for February of 2011.

3. On June 28, 2011 at 12:15 p.m., a kick-down door prop was found on the CT room exit door.

4. On June 28, 2011 at 12:20 p.m., the cross-corridor doors between the OB hallway and the Nursing Administrator's office did not close and latch.

5. On June 28, 2011 at 12:22 p.m., the cross-corridor doors between the OB hallway and the Nursing Administrator's office had rating labels that were painted over.

6. On June 28, 2011 at 12:44 p.m., the Clean Linen closet by Room 106 had no automatic closure.

Based on observations and interview it was determined that the facility failed to install/maintain approved doors and/or opening protectives in fire separations, exit passageways, stairway enclosures, and/or hazardous area enclosures. This resulted in the potential for the spread of fire/smoke during hostile fire events. (LSC 8.2.5.2, 19.3.6). Findings include, but are not limited to:

1. On June 28, 2011 at 11:33 a.m., the windows and doors open to the temporary tunnel were not rated for an exit passageway at 90 minutes..

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). 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). Findings include, but are not limited to:

1. On June 28, 2011 at 12:23 p.m., the Housekeeping closet doors by Rooms 117 and 119 had vents installed and no automatic closers.

2. On June 28, 2011 at 12:26 p.m., the closet by Room 119 had a stop installed on the track, preventing it from closing completely.

3. On June 28, 2011 at 12:30 p.m., the closet by the Nursery had a vent installed on the door.

4. On June 28, 2011 at 12:44 p.m., there was a vent found on the Housekeeping closet across the hall from the Nurse's Station.

5. On June 28, 2011 at 12:44 p.m., the door to the Soiled Linen closet by Room 104 was not latching.

Based on observations and interview it was determined that the facility failed to provide adequate travel distance to exits. This resulted in the potential for the delay of patients & staff in reaching an exit or other smoke compartments in a timely manner during a hostile fire event (LSC 7.1, 19.2.1, 19.2.5.10). Findings include, but are not limited to:

1. On June 28, 2011 at 11:33 a.m., the temporary tunnel length measured 170 feet from the Lobby door to the exit, with an additional 30 feet from the Hospital corridor to the exit.

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, 19.2.1, 19.2.5.10). Findings include, but are not limited to:

1. On June 28, 2011 at 12:50 p.m., the exterior exit from the patient care corridor by the Rehabilitation Services office did not measure at least four-feet in width and was not constructed of a hard surface.

2. On June 28, 2011 at 12:50 p.m., the exterior exit door from the patient care corridor by the Rehabilitation Services office did not have code compliant hardware for unlatching the door.

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, 38.2). Findings include, but are not limited to:

1. On June 28, 2011 at 2:28 p.m., the door leading to the Courtyard was marked as an exit.

Based on observations and interview it was determined that the facility failed to ensure emergency illumination in the event of a power outage. This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions (LSC 19.2.8). Findings include, but are not limited to:

1. On June 28, 2011 at 2:54 p.m., battery-powered emergency lighting was not provided in the Operating Room.

Based on observations, interview and record review it was determined that the facility failed to properly identify exits. This resulted in the potential for panic and confusion during an evacuation (LSC 19.7.1.1). Findings include, but are not limited to:

1. On June 28, 2011 at 11:36 a.m., the exit sign at the Nurse's Station to the Lobby was not located above the doors leading to the Administration area.

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). Findings include, but are not limited to:

1. On June 28, 2011 at 11:32 p.m., the facility did not implement interim life safety measures for alterations to exiting during construction.

2. On June 28, 2011 at 2:00 p.m., the emergency preparedness plan located at the Nurse's Station was reviewed and found to have the following deficiencies: There was no hazard assessment of the facility; the manual was last revised in 2009; the plan was not signed that it was reviewed by the Safety Committee; no transportation or transfer agreements were included; Policy 401A dated 5/07 stated to evacuate the building (RACE), but staff was trained to relocate (RACER); Policy 202 dated 5/07 stated that only the Charge Nurse could approve evacuating the facility for a fire and indicated the use of "Code Yellow" instead of "Code Red"; transfer sites identified by policy included the community building or Coquille Valley Middle School, no equivalent facilities were identified for long-term transfer situations; there were no maps with utility shut-offs; Policy 203 dated 5/07 did not identify how to manually start the generator; and the plan did not include responses for HAZMAT incidents or extreme weather.

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). Findings include, but are not limited to:

1. On June 28, 2011 at 10:45 a.m., a review of the fire drill records indicated that on March 27, 2010, the Day and NOC Shifts both counted false alarms from the fire alarm system as 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 38.7.1, 4.7). Findings include, but are not limited to:

1. On June 28, 2011 at 2:47 p.m., the facility did not have records of conducting an annual fire drill.

Based on observations, record review and interviews it was determined 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 June 28, 2011 at 10:45 p.m., maintenance forms for weekly, monthly and quarterly inspection of the fire alarm system were found to be outdated and not in accordance with adopted standards.

2. On June 28, 2011 at 10:45 a.m., the facility did not have access to the adopted standard of NFPA 72 for maintaining the fire alarm system.

3. On June 28, 2011 at 10:45 a.m., per interview with the Maintenance Supervisor, staff had no documentation of training to perform maintenance on the fire alarm system.

4. On June 28, 2011 at 10:45 a.m., a review of the facility's records indicated that the fire alarm system did not have a current sensitivity test of the smoke detectors.

5. On June 28, 2011 at 11:37 a.m., the fire alarm pull stations were installed 60-inches above the floor near the Nurse's Station and throughout the facility per interview.

6. On June 28, 2011 at 12:13 p.m., the fire alarm control panel was accessible to the general public and unsecured in the closet in the Medical Imaging corridor.

7. On June 28, 2011 at 12:42 p.m., there was no smoke detector found at the Nurse's Station that was open to the corridor.

Based on observations, record review and interviews it was determined 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 June 28, 2011 at 2:38 p.m., a fire alarm strobe was found in Procedure Room 34.

2. On June 28, 2011 at 2:42 p.m., the fire alarm system was not on a dedicated power supply.

3. On June 28, 2011 at 2:42 p.m., the fire alarm junction boxes were not painted red and there was not a sign on the door leading to the fire alarm control panel indicating the location.

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). Findings include, but are not limited to:

1. On June 28, 2011 at 12:13 p.m., the closet housing the fire alarm control panel next to the Medical Imaging corridor was not protected by fire sprinklers.

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). Findings include, but are not limited to:

1. On June 28, 2011 at 10:45 a.m., the facility could not locate documentation for the annual forward flow test of the fire sprinkler system.

2. On June 28, 2011 at 10:45 p.m., maintenance forms for weekly, monthly and quarterly inspection of the fire sprinkler system were found to be outdated and not in accordance with adopted standards.

3. On June 28, 2011 at 10:45 a.m., the facility did not have access to the adopted standard of NFPA 25 for maintaining the fire sprinkler system.

4. On June 28, 2011 at 10:45 a.m., per interview with the Maintenance Supervisor, staff had no documentation of training to perform maintenance on the fire sprinkler system.

5. On June 28, 2011 at 11:31 a.m., corroded fire sprinkler heads were found in the overhang of the Emergency Department entrance.

6. On June 28, 2011 at 11:32 a.m., the temporary tunnel to the Main Entrance to the Hospital was not adequately covered by fire sprinklers.

7. On June 28, 2011 at 12:04 p.m., the water pressure gauges on the fire sprinkler riser were dated 1969 and were past due for a five-year replacement/calibration since 1974.

8. On June 28, 2011 at 12:08 p.m., the fire department connection was missing a sign with six-inch letters (red on white/white on red) that was visible from the road.

9. On June 28, 2011 at 12:28 p.m., a fire sprinkler head in the Clean Linen closet by Room 119 had drywall texturing on it.

10. On June 28, 2011 at 12:44 p.m., a fire sprinkler head in the Clean Linen closet by Room 106 had drywall texturing on it.

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). Findings include, but are not limited to:

1. On June 28, 2011 at 2:29 p.m., the gauges reading the water pressure for the fire suppression system were dated 2004 and were past due for a five-year calibration/replacement.

2. On June 28, 2011 at 2:29 p.m., the door leading to the fire sprinkler control valve did not have a sign indicating the location.

3. On June 28, 2011 at 2:46 p.m., a fire sprinkler was missing an escutcheon plate above Room 15.

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). Findings include, but are not limited to:

1. On June 28, 2011 at 10:45 p.m., maintenance forms for weekly, monthly and quarterly inspection of the fire extinguishers were found to be outdated and not in accordance with adopted standards.

2. On June 28, 2011 at 10:45 a.m., the facility did not have access to the adopted standard of NFPA 10 for maintaining fire extinguishers.

3. On June 28, 2011 at 10:45 a.m., the facility did not have any previous documentation of maintenance or inspection of the fire extinguishers.

4. On June 28, 2011 at 11:49 am, the fire extinguisher in the Admitting area was installed more than 60-inches from the floor and was obstructed by a file cabinet. Fire extinguishers throughout the facility were installed more than 60-inches from the floor to the handle per interview.

5. On June 28, 2011 at 12:07 p.m., the fire extinguisher in the Mechanical Room was obstructed.

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 38.3.5, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:

1. On June 28, 2011 at 2:31 p.m., a fire extinguisher located on the second floor Medical Records Storage did not have initials on the tag indicating that it had been inspected by staff monthly.

2. On June 28, 2011 at 2:34 p.m., a fire extinguisher was found sitting on the floor by Exam Room 1.

3. On June 28, 2011 at 2:37 p.m., a fire extinguisher was mounted too high above the floor by the exit near the General Surgery MD.

Based upon record reviews, observations and interviews it was determined that the facility failed to ensure safe smoking practices by residents in the facility in accordance with facility policies and life safety regulations. This resulted in the potential for exposing residents to a fire and/or smoke environment (LSC 19.7.4). Findings include, but are not limited to:

1. On June 28, 2011 at 12:19 p.m., cigarette butts were found on the ground outside of the Nursing Administrator's office. The facility had a "no-smoking" policy on campus for staff and visitors.

Based on observations, record review and interviews it was determined that the facility failed to properly install building service equipment. This resulted in the potential for a gas leak and unexpected fire (LSC 38.5.2, 9.2, NFPA 90A). Findings include, but are not limited to:

1. On June 28, 2011 at 2:32 p.m., the water heater on the second floor was missing seismic strapping.

Based on observations, record review and interviews it was determined that the facility failed to properly install/maintain building service equipment. This resulted in the potential for failure of heating, ventilating, or air conditioning building service equipment and the unwanted passage of smoke through the ventilation system (LSC 19.5.2.1, 19.5.2.2, 9.2, NFPA 90A). Findings include, but are not limited to:

1. On June 28, 2011 at 10:45 a.m., a review of the facility's records indicated that there was no documentation of smoke and fire damper maintenance.

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). Findings include, but are not limited to:

1. On June 28, 2011 at 10:45 a.m., records indicated that the kitchen hood fire suppression system was last serviced in June of 2010, and was past due for 6-month maintenance.

Based on observations, record review and interviews it was determined that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" up to 80" above the floor. 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 June 28, 2011 at 11:34 a.m., the Lobby exit was not maintained 8-foot clear width, due to furnishings.

2. On June 28, 2011 at 11:38 a.m., unattended carts, wheelchairs, blood pressure machines, and linen/trash carts were found to be stored in the lobby since 8:45 a.m. when surveyors arrived.

3. On June 28, 2011 at 11:58 a.m., chairs and carts were found to be obstructing the corridor near Radiology.

4. On June 28, 2011 at 12:18 p.m., wooden doors and a patient bed were found stored in the corridor by Materials Management at the exit door.

Based on observations, record review and interviews it was determined that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" up to 80" above the floor. 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 June 28, 2011 at 2:45 p.m., a barbecue grill was placed in the exterior exit path by Room 14.

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). Findings include, but are not limited to:

1. On June 28,2011 at 12:34 p.m., office spaces with combustible furnishings were found in the corridor serving the Surgery Suite.

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 38.3.2). Findings include, but are not limited to:

1. On June 28, 2011 at 2:32 p.m., combustible storage was found in the attic area.

Based upon observations and interviews it was determined that the facility failed to ensure that no storage of highly flammable character existed in the corridors. This resulted in the potential for excessive fire spread (LSC 19.7.5.5, Exhibit 19.23). Findings include, but are not limited to:

1. On June 28, 2011 at 12:30 p.m., a trash can measuring over 32-gallons was found outside of the Recovery Room in the corridor.

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. 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). Findings include, but are not limited to:

1. On June 28, 2011 at 12:12 p.m., the gas line serving the water heater was not secured.

2. On June 28, 2011 at 12:51 p.m., oxygen was found stored in the Respiratory Therapist's office closet with a light switch located within 60-inches of the floor.

3. On June 28, 2011 at 2:07 p.m., the Oxygen Storage Room has compressed bottles that are secured with only one chain.

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 patients during medical procedures and created a hazardous area for the surrounding area (LSC 19.3.2.4, 4.3.1.1.2). Findings include, but are not limited to:

1. On June 28, 2011 at 2:16 p.m., the concrete parking pad next to the bulk liquid oxygen tank was too small and there was no curbing for spill protection provided.

Based on observations and interview it was determined that the facility failed to maintain dryers (NFPA 54). This resulted in the potential for unexpected ignition source & excessive fire spread. Findings include, but are not limited to:

1. On June 28, 2011 at 12:06 p.m., excessive lint was found in the Laundry Dryer.

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) Findings include, but are not limited to:

1. On June 28, 2011 at 10:45 p.m., records indicated that the facility was past due for the four-hour load bank test of the generator that is due every 3 years. The Maintenance Supervisor indicated that this test has never been done and he was not familiar with the requirement per interview.

2. On June 28, 2011 at 10:45 p.m., maintenance forms for weekly, monthly and quarterly inspection of the generator were found to be outdated and not in accordance with adopted standards.

3. On June 28, 2011 at 10:45 a.m., the facility did not have access to the adopted standard of NFPA 110 for maintaining the generator.

3. On June 28, 2011 at 10:45 a.m., per interview with the Maintenance Supervisor, staff had no documentation of training to perform maintenance on the generator.

4. On June 28, 2011 at 11:59 a.m., the generator was found to have maintenance-free batteries.

5. On June 28, 2011 at 12:03 p.m., there was no battery-powered emergency light located at the generator.

6. On June 28, 2011 at 12:05 p.m., there was no emergency shut-off located remotely from the generator.

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 (NEC 110-3.8). Findings include, but are not limited to:

1. On June 28, 2011 at 2:30 p.m., a relocatable power tap was found in the Reception office area.

2. On June 28, 2011 at 2:32 p.m., a relocatable power tap was plugged into a 6 to 2 outlet plug adapter in the Reception area.

3. On June 28, 2011 at 2:36 p.m., a household-use microwave and toaster were found in the Break 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). Findings include, but are not limited to:

1. On June 28, 2011 at 11:32 a.m., vending machines were found to be plugged into an extension cord in the temporary tunnel.

2. On June 28, 2011 at 11:33 a.m., an extension cord was found serving the lights for the cabinet behind the Lobby Reception desk.

3. On June 28, 2011 at 11:34 a.m., an extension cord was found serving two lamps in the Lobby.

4. On June 28, 2011 at 11:48 a.m., relocatable power taps were found at the Admitting desks.

5. On June 28, 2011 at 11:53 a.m., a household-use microwave was found in the Dining Room.

6. On June 28, 2011 at 11:53 a.m., a three-way plug adapter was found serving the coffee maker and water dispenser in the Dining Room.

7. On June 28, 2011 at 11:54 a.m., a relocatable power tap was found on the floor of the Dietary Office.

8. On June 28, 2011 at 11:55 a.m., a household-use microwave was found in the Kitchen.

9. On June 28, 2011 at 11:56 a.m., an extension cord was found serving a household-use microwave in the Kitchen next to the Dish Sink.

10. On June 28, 2011 at 11:57 a.m., a household-use hot plate was found in the Kitchen.

11. On June 28, 2011 at 11:58 a.m., the chemical closet in Radiology had an electrical outlet that was missing a cover.

12. On June 28, 2011 at 12:20 p.m., a relocatable power tap was found in the Nursing Administrator's office.

13. On June 28, 2011 at 12:29 p.m., relocatable power taps were found interconnected outside the Recovery Room on a cart.

14. On June 28, 2011 at 12:33 p.m., two relocatable power taps were found in the IT office.

15. On June 28, 2011 at 12:35 p.m., a relocatable power tap was found by the blanket warmer in the Emergency Department.

16. On June 28, 2011 at 12:37 p.m., a 6 to 2 outlet plug adapter was found in the Lab.

17. On June 28, 2011 at 12:45 p.m., a relocatable power tap with wire molding was found by Room 106.

18. On June 28, 2011 at 12:47 p.m., two relocatable power taps were found in Room 109.

19. On June 28, 2011 at 12:48 p.m., a relocatable power tap was found in the Respiratory Therapist's office.

20. On June 28, 2011 at 12:49 p.m., a relocatable power tap was found in the Materials Management office.

21. On June 28, 2011 at 12:50 p.m., an extension cord serving a coffee pot was found in Rehabilitation Services.

22. On June 28, 2011 at 2:54 p.m., a household-use microwave was found in the Operating Room corridor.

23. On June 28, 2011 at 2:55 p.m., a non-patient use relocatable power tap was found in the Recovery Room.

Based on record review and interviews it was determined that the facility failed to have a plan to address either a planned or unplanned fire sprinkler system shutdown that identified their procedures to follow when the fire sprinkler system was unavailable. This potentially prevents early notification of smoke &/or fire that delays evacuation of patients & staff to a safe refuge. Findings include, but are not limited to:

1. On June 28, 2011 at 2:00 p.m., the facility's fire watch policies did not include to notify OSFM for fires, explosions or evacuations.

Based on record review and interviews it was determined that the facility failed to have a plan to address either a planned or unplanned fire alarm system shutdown that identified their procedures to follow when the fire alarm system was unavailable. This potentially prevents early notification of smoke &/or fire that delays evacuation of residents/patients & staff to a safe refuge. Findings include, but are not limited to:

1. On June 28, 2011 at 10:45 a.m., a review of records indicated that the facility failed to perform a fire watch March 27, 2011 through April 5, 2011, when the fire alarm system malfunctioned.

2. On June 28, 2011 at 10:45 a.m., a review of records indicated that on June 7, 2010 the Night Shift staff experienced a fire alarm malfunction, where they checked the building and determined that the alarm was false. Staff canceled the fire department response and contacted the fire alarm monitoring company to report the alarm as false. No fire watch was documented. The alarm was recorded as a fire drill.

3. On June 28, 2011 at 2:00 p.m., the facility's fire watch policies did not include to notify OSFM for fires, explosions or evacuations.

Based on observations and interview it was determined 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). Findings include, but are not limited to:

1. On June 28, 2011 at 11:44 a.m., the doors from the Nurse's Station to the Administration area did not provide proper smoke separation.

2. On June 28, 2011 at 11:45 a.m., the facility was not separated into two smoke compartments.

3. On June 28, 2011 at 12:24 p.m., the fire wall was found to be unfinished between the OB hallway and the Nursing Administrator's office.

4. On June 28, 2011 at 12:28 p.m., there was no smoke separation found between the Operating Room and the OB corridor.

5. On June 28, 2011 at 12:32 p.m., there was no smoke separation found between the OB corridor and the Surgical Services corridor.

6. On June 28, 2011 at 12:35 p.m., the doors between the Emergency Department and the Surgery corridor were not rated for smoke separation.

7. On June 28, 2011 at 12:38 p.m., there was no smoke separation between the Operating Room corridor and the Radiology corridor.

8. On June 28, 2011 at 12:47 p.m., unsealed ceiling penetrations were found throughout the Patient Rooms. Per interview with the Maintenance Supervisor, this condition existed throughout the patient wing as smoke detectors were relocated.

9. On June 28, 2011 at 12:49 p.m., an unsealed ceiling penetration was found in the Materials Management 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). Findings include, but are not limited to:

1. On June 28, 2011 at 11:44 a.m., the facility was not able to provide fire and life safety plans for the building to confirm the location of fire and smoke separations.

2. On June 28, 2011 at 12:16 p.m., unsealed penetrations were found in the two-hour fire wall between the CT corridor and the Purchasing office.

3. On June 28, 2011 at 12:40 p.m., unsealed wall penetrations were found in the Ultrasound Room.

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). Findings include, but are not limited to:

1. On June 28, 2011 at 10:45 a.m., maintenance forms for weekly, monthly and quarterly inspections of the fire and smoke doors were outdated and not in accordance with adopted standards, nor did the facility have access to NFPA 80, 1999 Edition in order to inspect, maintain, & test doors.

2. On June 28, 2011 at 10:45 a.m., the facility was missing documentation of maintenance on the smoke and fire doors for February of 2011.

3. On June 28, 2011 at 12:15 p.m., a kick-down door prop was found on the CT room exit door.

4. On June 28, 2011 at 12:20 p.m., the cross-corridor doors between the OB hallway and the Nursing Administrator's office did not close and latch.

5. On June 28, 2011 at 12:22 p.m., the cross-corridor doors between the OB hallway and the Nursing Administrator's office had rating labels that were painted over.

6. On June 28, 2011 at 12:44 p.m., the Clean Linen closet by Room 106 had no automatic closure.

Based on observations and interview it was determined that the facility failed to install/maintain approved doors and/or opening protectives in fire separations, exit passageways, stairway enclosures, and/or hazardous area enclosures. This resulted in the potential for the spread of fire/smoke during hostile fire events. (LSC 8.2.5.2, 19.3.6). Findings include, but are not limited to:

1. On June 28, 2011 at 11:33 a.m., the windows and doors open to the temporary tunnel were not rated for an exit passageway at 90 minutes..

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). 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). Findings include, but are not limited to:

1. On June 28, 2011 at 12:23 p.m., the Housekeeping closet doors by Rooms 117 and 119 had vents installed and no automatic closers.

2. On June 28, 2011 at 12:26 p.m., the closet by Room 119 had a stop installed on the track, preventing it from closing completely.

3. On June 28, 2011 at 12:30 p.m., the closet by the Nursery had a vent installed on the door.

4. On June 28, 2011 at 12:44 p.m., there was a vent found on the Housekeeping closet across the hall from the Nurse's Station.

5. On June 28, 2011 at 12:44 p.m., the door to the Soiled Linen closet by Room 104 was not latching.

Based on observations and interview it was determined that the facility failed to provide adequate travel distance to exits. This resulted in the potential for the delay of patients & staff in reaching an exit or other smoke compartments in a timely manner during a hostile fire event (LSC 7.1, 19.2.1, 19.2.5.10). Findings include, but are not limited to:

1. On June 28, 2011 at 11:33 a.m., the temporary tunnel length measured 170 feet from the Lobby door to the exit, with an additional 30 feet from the Hospital corridor to the exit.

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, 19.2.1, 19.2.5.10). Findings include, but are not limited to:

1. On June 28, 2011 at 12:50 p.m., the exterior exit from the patient care corridor by the Rehabilitation Services office did not measure at least four-feet in width and was not constructed of a hard surface.

2. On June 28, 2011 at 12:50 p.m., the exterior exit door from the patient care corridor by the Rehabilitation Services office did not have code compliant hardware for unlatching the door.

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, 38.2). Findings include, but are not limited to:

1. On June 28, 2011 at 2:28 p.m., the door leading to the Courtyard was marked as an exit.

Based on observations and interview it was determined that the facility failed to ensure emergency illumination in the event of a power outage. This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions (LSC 19.2.8). Findings include, but are not limited to:

1. On June 28, 2011 at 2:54 p.m., battery-powered emergency lighting was not provided in the Operating Room.

Based on observations, interview and record review it was determined that the facility failed to properly identify exits. This resulted in the potential for panic and confusion during an evacuation (LSC 19.7.1.1). Findings include, but are not limited to:

1. On June 28, 2011 at 11:36 a.m., the exit sign at the Nurse's Station to the Lobby was not located above the doors leading to the Administration area.

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). Findings include, but are not limited to:

1. On June 28, 2011 at 11:32 p.m., the facility did not implement interim life safety measures for alterations to exiting during construction.

2. On June 28, 2011 at 2:00 p.m., the emergency preparedness plan located at the Nurse's Station was reviewed and found to have the following deficiencies: There was no hazard assessment of the facility; the manual was last revised in 2009; the plan was not signed that it was reviewed by the Safety Committee; no transportation or transfer agreements were included; Policy 401A dated 5/07 stated to evacuate the building (RACE), but staff was trained to relocate (RACER); Policy 202 dated 5/07 stated that only the Charge Nurse could approve evacuating the facility for a fire and indicated the use of "Code Yellow" instead of "Code Red"; transfer sites identified by policy included the community building or Coquille Valley Middle School, no equivalent facilities were identified for long-term transfer situations; there were no maps with utility shut-offs; Policy 203 dated 5/07 did not identify how to manually start the generator; and the plan did not include responses for HAZMAT incidents or extreme weather.

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). Findings include, but are not limited to:

1. On June 28, 2011 at 10:45 a.m., a review of the fire drill records indicated that on March 27, 2010, the Day and NOC Shifts both counted false alarms from the fire alarm system as 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 38.7.1, 4.7). Findings include, but are not limited to:

1. On June 28, 2011 at 2:47 p.m., the facility did not have records of conducting an annual fire drill.

Based on observations, record review and interviews it was determined 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 June 28, 2011 at 10:45 p.m., maintenance forms for weekly, monthly and quarterly inspection of the fire alarm system were found to be outdated and not in accordance with adopted standards.

2. On June 28, 2011 at 10:45 a.m., the facility did not have access to the adopted standard of NFPA 72 for maintaining the fire alarm system.

3. On June 28, 2011 at 10:45 a.m., per interview with the Maintenance Supervisor, staff had no documentation of training to perform maintenance on the fire alarm system.

4. On June 28, 2011 at 10:45 a.m., a review of the facility's records indicated that the fire alarm system did not have a current sensitivity test of the smoke detectors.

5. On June 28, 2011 at 11:37 a.m., the fire alarm pull stations were installed 60-inches above the floor near the Nurse's Station and throughout the facility per interview.

6. On June 28, 2011 at 12:13 p.m., the fire alarm control panel was accessible to the general public and unsecured in the closet in the Medical Imaging corridor.

7. On June 28, 2011 at 12:42 p.m., there was no smoke detector found at the Nurse's Station that was open to the corridor.

Based on observations, record review and interviews it was determined 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 June 28, 2011 at 2:38 p.m., a fire alarm strobe was found in Procedure Room 34.

2. On June 28, 2011 at 2:42 p.m., the fire alarm system was not on a dedicated power supply.

3. On June 28, 2011 at 2:42 p.m., the fire alarm junction boxes were not painted red and there was not a sign on the door leading to the fire alarm control panel indicating the location.

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). Findings include, but are not limited to:

1. On June 28, 2011 at 12:13 p.m., the closet housing the fire alarm control panel next to the Medical Imaging corridor was not protected by fire sprinklers.

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). Findings include, but are not limited to:

1. On June 28, 2011 at 10:45 a.m., the facility could not locate documentation for the annual forward flow test of the fire sprinkler system.

2. On June 28, 2011 at 10:45 p.m., maintenance forms for weekly, monthly and quarterly inspection of the fire sprinkler system were found to be outdated and not in accordance with adopted standards.

3. On June 28, 2011 at 10:45 a.m., the facility did not have access to the adopted standard of NFPA 25 for maintaining the fire sprinkler system.

4. On June 28, 2011 at 10:45 a.m., per interview with the Maintenance Supervisor, staff had no documentation of training to perform maintenance on the fire sprinkler system.

5. On June 28, 2011 at 11:31 a.m., corroded fire sprinkler heads were found in the overhang of the Emergency Department entrance.

6. On June 28, 2011 at 11:32 a.m., the temporary tunnel to the Main Entrance to the Hospital was not adequately covered by fire sprinklers.

7. On June 28, 2011 at 12:04 p.m., the water pressure gauges on the fire sprinkler riser were dated 1969 and were past due for a five-year replacement/calibration since 1974.

8. On June 28, 2011 at 12:08 p.m., the fire department connection was missing a sign with six-inch letters (red on white/white on red) that was visible from the road.

9. On June 28, 2011 at 12:28 p.m., a fire sprinkler head in the Clean Linen closet by Room 119 had drywall texturing on it.

10. On June 28, 2011 at 12:44 p.m., a fire sprinkler head in the Clean Linen closet by Room 106 had drywall texturing on it.

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). Findings include, but are not limited to:

1. On June 28, 2011 at 2:29 p.m., the gauges reading the water pressure for the fire suppression system were dated 2004 and were past due for a five-year calibration/replacement.

2. On June 28, 2011 at 2:29 p.m., the door leading to the fire sprinkler control valve did not have a sign indicating the location.

3. On June 28, 2011 at 2:46 p.m., a fire sprinkler was missing an escutcheon plate above Room 15.

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). Findings include, but are not limited to:

1. On June 28, 2011 at 10:45 p.m., maintenance forms for weekly, monthly and quarterly inspection of the fire extinguishers were found to be outdated and not in accordance with adopted standards.

2. On June 28, 2011 at 10:45 a.m., the facility did not have access to the adopted standard of NFPA 10 for maintaining fire extinguishers.

3. On June 28, 2011 at 10:45 a.m., the facility did not have any previous documentation of maintenance or inspection of the fire extinguishers.

4. On June 28, 2011 at 11:49 am, the fire extinguisher in the Admitting area was installed more than 60-inches from the floor and was obstructed by a file cabinet. Fire extinguishers throughout the facility were installed more than 60-inches from the floor to the handle per interview.

5. On June 28, 2011 at 12:07 p.m., the fire extinguisher in the Mechanical Room was obstructed.

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 38.3.5, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:

1. On June 28, 2011 at 2:31 p.m., a fire extinguisher located on the second floor Medical Records Storage did not have initials on the tag indicating that it had been inspected by staff monthly.

2. On June 28, 2011 at 2:34 p.m., a fire extinguisher was found sitting on the floor by Exam Room 1.

3. On June 28, 2011 at 2:37 p.m., a fire extinguisher was mounted too high above the floor by the exit near the General Surgery MD.

Based upon record reviews, observations and interviews it was determined that the facility failed to ensure safe smoking practices by residents in the facility in accordance with facility policies and life safety regulations. This resulted in the potential for exposing residents to a fire and/or smoke environment (LSC 19.7.4). Findings include, but are not limited to:

1. On June 28, 2011 at 12:19 p.m., cigarette butts were found on the ground outside of the Nursing Administrator's office. The facility had a "no-smoking" policy on campus for staff and visitors.

Based on observations, record review and interviews it was determined that the facility failed to properly install building service equipment. This resulted in the potential for a gas leak and unexpected fire (LSC 38.5.2, 9.2, NFPA 90A). Findings include, but are not limited to:

1. On June 28, 2011 at 2:32 p.m., the water heater on the second floor was missing seismic strapping.

Based on observations, record review and interviews it was determined that the facility failed to properly install/maintain building service equipment. This resulted in the potential for failure of heating, ventilating, or air conditioning building service equipment and the unwanted passage of smoke through the ventilation system (LSC 19.5.2.1, 19.5.2.2, 9.2, NFPA 90A). Findings include, but are not limited to:

1. On June 28, 2011 at 10:45 a.m., a review of the facility's records indicated that there was no documentation of smoke and fire damper maintenance.

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). Findings include, but are not limited to:

1. On June 28, 2011 at 10:45 a.m., records indicated that the kitchen hood fire suppression system was last serviced in June of 2010, and was past due for 6-month maintenance.

Based on observations, record review and interviews it was determined that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" up to 80" above the floor. 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 June 28, 2011 at 11:34 a.m., the Lobby exit was not maintained 8-foot clear width, due to furnishings.

2. On June 28, 2011 at 11:38 a.m., unattended carts, wheelchairs, blood pressure machines, and linen/trash carts were found to be stored in the lobby since 8:45 a.m. when surveyors arrived.

3. On June 28, 2011 at 11:58 a.m., chairs and carts were found to be obstructing the corridor near Radiology.

4. On June 28, 2011 at 12:18 p.m., wooden doors and a patient bed were found stored in the corridor by Materials Management at the exit door.

Based on observations, record review and interviews it was determined that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" up to 80" above the floor. 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 June 28, 2011 at 2:45 p.m., a barbecue grill was placed in the exterior exit path by Room 14.

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). Findings include, but are not limited to:

1. On June 28,2011 at 12:34 p.m., office spaces with combustible furnishings were found in the corridor serving the Surgery Suite.

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 38.3.2). Findings include, but are not limited to:

1. On June 28, 2011 at 2:32 p.m., combustible storage was found in the attic area.

Based upon observations and interviews it was determined that the facility failed to ensure that no storage of highly flammable character existed in the corridors. This resulted in the potential for excessive fire spread (LSC 19.7.5.5, Exhibit 19.23). Findings include, but are not limited to:

1. On June 28, 2011 at 12:30 p.m., a trash can measuring over 32-gallons was found outside of the Recovery Room in the corridor.

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. 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). Findings include, but are not limited to:

1. On June 28, 2011 at 12:12 p.m., the gas line serving the water heater was not secured.

2. On June 28, 2011 at 12:51 p.m., oxygen was found stored in the Respiratory Therapist's office closet with a light switch located within 60-inches of the floor.

3. On June 28, 2011 at 2:07 p.m., the Oxygen Storage Room has compressed bottles that are secured with only one chain.

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 patients during medical procedures and created a hazardous area for the surrounding area (LSC 19.3.2.4, 4.3.1.1.2). Findings include, but are not limited to:

1. On June 28, 2011 at 2:16 p.m., the concrete parking pad next to the bulk liquid oxygen tank was too small and there was no curbing for spill protection provided.

Based on observations and interview it was determined that the facility failed to maintain dryers (NFPA 54). This resulted in the potential for unexpected ignition source & excessive fire spread. Findings include, but are not limited to:

1. On June 28, 2011 at 12:06 p.m., excessive lint was found in the Laundry Dryer.

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) Findings include, but are not limited to:

1. On June 28, 2011 at 10:45 p.m., records indicated that the facility was past due for the four-hour load bank test of the generator that is due every 3 years. The Maintenance Supervisor indicated that this test has never been done and he was not familiar with the requirement per interview.

2. On June 28, 2011 at 10:45 p.m., maintenance forms for weekly, monthly and quarterly inspection of the generator were found to be outdated and not in accordance with adopted standards.

3. On June 28, 2011 at 10:45 a.m., the facility did not have access to the adopted standard of NFPA 110 for maintaining the generator.

3. On June 28, 2011 at 10:45 a.m., per interview with the Maintenance Supervisor, staff had no documentation of training to perform maintenance on the generator.

4. On June 28, 2011 at 11:59 a.m., the generator was found to have maintenance-free batteries.

5. On June 28, 2011 at 12:03 p.m., there was no battery-powered emergency light located at the generator.

6. On June 28, 2011 at 12:05 p.m., there was no emergency shut-off located remotely from the generator.

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 (NEC 110-3.8). Findings include, but are not limited to:

1. On June 28, 2011 at 2:30 p.m., a relocatable power tap was found in the Reception office area.

2. On June 28, 2011 at 2:32 p.m., a relocatable power tap was plugged into a 6 to 2 outlet plug adapter in the Reception area.

3. On June 28, 2011 at 2:36 p.m., a household-use microwave and toaster were found in the Break 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). Findings include, but are not limited to:

1. On June 28, 2011 at 11:32 a.m., vending machines were found to be plugged into an extension cord in the temporary tunnel.

2. On June 28, 2011 at 11:33 a.m., an extension cord was found serving the lights for the cabinet behind the Lobby Reception desk.

3. On June 28, 2011 at 11:34 a.m., an extension cord was found serving two lamps in the Lobby.

4. On June 28, 2011 at 11:48 a.m., relocatable power taps were found at the Admitting desks.

5. On June 28, 2011 at 11:53 a.m., a household-use microwave was found in the Dining Room.

6. On June 28, 2011 at 11:53 a.m., a three-way plug adapter was found serving the coffee maker and water dispenser in the Dining Room.

7. On June 28, 2011 at 11:54 a.m., a relocatable power tap was found on the floor of the Dietary Office.

8. On June 28, 2011 at 11:55 a.m., a household-use microwave was found in the Kitchen.

9. On June 28, 2011 at 11:56 a.m., an extension cord was found serving a household-use microwave in the Kitchen next to the Dish Sink.

10. On June 28, 2011 at 11:57 a.m., a household-use hot plate was found in the Kitchen.

11. On June 28, 2011 at 11:58 a.m., the chemical closet in Radiology had an electrical outlet that was missing a cover.

12. On June 28, 2011 at 12:20 p.m., a relocatable power tap was found in the Nursing Administrator's office.

13. On June 28, 2011 at 12:29 p.m., relocatable power taps were found interconnected outside the Recovery Room on a cart.

14. On June 28, 2011 at 12:33 p.m., two relocatable power taps were found in the IT office.

15. On June 28, 2011 at 12:35 p.m., a relocatable power tap was found by the blanket warmer in the Emergency Department.

16. On June 28, 2011 at 12:37 p.m., a 6 to 2 outlet plug adapter was found in the Lab.

17. On June 28, 2011 at 12:45 p.m., a relocatable power tap with wire molding was found by Room 106.

18. On June 28, 2011 at 12:47 p.m., two relocatable power taps were found in Room 109.

19. On June 28, 2011 at 12:48 p.m., a relocatable power tap was found in the Respiratory Therapist's office.

20. On June 28, 2011 at 12:49 p.m., a relocatable power tap was found in the Materials Management office.

21. On June 28, 2011 at 12:50 p.m., an extension cord serving a coffee pot was found in Rehabilitation Services.

22. On June 28, 2011 at 2:54 p.m., a household-use microwave was found in the Operating Room corridor.

23. On June 28, 2011 at 2:55 p.m., a non-patient use relocatable power tap was found in the Recovery Room.

Based on record review and interviews it was determined that the facility failed to have a plan to address either a planned or unplanned fire sprinkler system shutdown that identified their procedures to follow when the fire sprinkler system was unavailable. This potentially prevents early notification of smoke &/or fire that delays evacuation of patients & staff to a safe refuge. Findings include, but are not limited to:

1. On June 28, 2011 at 2:00 p.m., the facility's fire watch policies did not include to notify OSFM for fires, explosions or evacuations.

Based on record review and interviews it was determined that the facility failed to have a plan to address either a planned or unplanned fire alarm system shutdown that identified their procedures to follow when the fire alarm system was unavailable. This potentially prevents early notification of smoke &/or fire that delays evacuation of residents/patients & staff to a safe refuge. Findings include, but are not limited to:

1. On June 28, 2011 at 10:45 a.m., a review of records indicated that the facility failed to perform a fire watch March 27, 2011 through April 5, 2011, when the fire alarm system malfunctioned.

2. On June 28, 2011 at 10:45 a.m., a review of records indicated that on June 7, 2010 the Night Shift staff experienced a fire alarm malfunction, where they checked the building and determined that the alarm was false. Staff canceled the fire department response and contacted the fire alarm monitoring company to report the alarm as false. No fire watch was documented. The alarm was recorded as a fire drill.

3. On June 28, 2011 at 2:00 p.m., the facility's fire watch policies did not include to notify OSFM for fires, explosions or evacuations.