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

1. On September 20, 2011 at 10:28 a.m., unsealed penetrations were found in the fire wall near doors 350-A and 306-A.

Based on observations and interviews it was determined that the facility failed to maintain integrity of smoke separations. This resulted in the potential for 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). Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. During the facility tour on September 20, 2011 from 9:00 a.m. to 3:40 p.m., unsealed wall penetrations were found in the First Floor Dining Room, First Floor Day Room, by the bell in Room 155-E, at the door in Room 146-W, above the door in Room 153-W, between 115-W and the Men's Toilet, B-108, B-113 and B-119.

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). Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 9:15 a.m., the facility did not have access to NFPA 80 (1999) for maintenance of fire doors and windows.

2. On September 20, 2011 at 9:30 a.m., the facility did not have documentation of required maintenance of smoke and fire doors, including monthly inspections.

3. On September 20, 2011 at 10:41 a.m., kick-down door props were found on doors 202-W, 206-W, on 2-W corridor offices, the Superintendent's Office, and the Restroom door in the Basement.

Based on observations and interview it was determined that the facility failed to maintain approved doors and/or opening protection in fire separations, exit passageways, stairway enclosures, and/or hazardous area enclosures. 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 19.3.1). Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 3:13 p.m., the Stair Door B-121 did not close and latch properly.

Based on observations, interviews 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). Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 3:13 p.m., the Stair Door B-121 was not properly marked.

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). Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 11:02 a.m., there was no automatic door closer on the storage room marked 249-W. This condition also existed on the door to 217-E.

2. On September 20, 2011 at 3:02 p.m., a vent was found in the corridor door B-119.

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

1. On September 20, 2011 at 11:49 a.m., there were no exterior lights (at least 2 bulbs) by the fire exit from 207-C. This condition also existed from the Basement Stairwell to the West side of the building.

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). Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 9:00 a.m., the facility's emergency preparedness plan was last updated 1/2010 and was past due for an annual review. The plan was also missing an annual hazard-risk analysis and written transportation and transfer agreements to an equivalent facility for relocation if needed during an evacuation.

Based on observations, record review and interviews it was determined that the facility failed to install fire alarm system in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 19.3.4, 9.6). Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 11:45 a.m., the fire alarm pull station in 253-E was mounted so that the handle was over 54-inches from the floor. This condition also existed in 102-W.

2. On September 20, 2011 at 1:30 p.m., there was no fire alarm pull station within five-feet of the Main Entrance. There was no pull station located in the Main Office corridor.

3. On September 20, 2011 at 1:35 p.m., the fire alarm box located in the Entrance Corridor was not painted red.

4. On September 20, 2011 at 3:12 p.m., the facility had no record of acceptance testing or permits of the fire alarm control panel that was installed in 2006 .

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 condition created a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient, which constitutes Immediate Jeopardy. Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 4:50 p.m., there was no documentation or evidence that the fire alarm system had been tested, inspected or maintained in accordance with NFPA 72 Standard by a qualified technician. The only records on-site indicated that the system had been tested/maintained in 4/2010, 12/2010, 4/2011 and 8/2011, but the facility could not provide any documentation that the person performing the work was qualified to do so. There was no documentation or tags that the system had ever been inspected, or that the new fire alarm control panel that was installed in 2006 was permitted or accepted. Interview indicated that the Maintenance Department was reorganized in 2009, and any documentation of the system before that time could not be located.

2. On September 20, 2011 at 2:10 p.m., the fire alarm pull station by Room 155-E was not accessible.

3. On September 20, 2011 at 3:12 p.m., there was not a current inspection tag on the fire alarm control panel, and the batteries were not dated.

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, OAR 333-535-0061(6)(j)). Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 10:49 a.m., the 215-W stairwell was not fully covered by fire sprinklers. This condition was also found in the stairwells by 253-W, 241-E and 153-W.

2. On September 20, 2011 at 11:10 a.m., the shower in Room 259-W was not covered by fire sprinklers. This condition was also found in 159-W, and 108-W.

3. On September 20, 2011 at 11:35 a.m., most of the fire sprinklers installed in patient areas were not approved for the occupancy type (psychiatric hospital). Examples of areas included were 251-E and the Men's Shower in the First Floor West Wing. There were also multiple areas where the sprinkler piping was exposed, which was a hazard to the patients.

4. On September 20, 2011 at 1:37 p.m., the fire sprinkler head installed in the Oxygen Storage Room under the stairs was not installed properly.

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 condition created a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient, which constitutes Immediate Jeopardy. Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 4:50 p.m., there was no documentation or evidence that the fire sprinkler system had been tested, inspected or maintained in accordance with NFPA 25 Standard by a qualified technician. The only records on-site indicated that the system had been tested/maintained in 4/2010, 12/2010, 4/2011 and 8/2011, but the facility could not provide any documentation that the person performing the work was qualified to do so. There was no documentation or tags that the system had ever been inspected. The Maintenance Department was reorganized in 2009, and any documentation of the system before that time could not be located.

2. During the facility tour on September 20, 2011 from 9:00 a.m. to 3:40 p.m., corroded, painted and/or dirty fire sprinkler heads were found 211-W, 214-W, by the entrance to the Women's Bathroom near 246-E, 253-E, 257-W Staffing Office Kitchen, in the corridor outside of 210-C, 105-E, in the Kitchen, in the Dishwashing area, 144, Men's & Women's Laundry/Shower area on the first floor, 155-E, 153-W, Shower Room 108-W, Men's Shower Room across from 137-W and in the corridor, next to 116-W, 121-W, 132-W, 103-C, B-133 and the restroom corridor.

3. On September 20, 2011 at 11:09 a.m., the water gauges on the fire sprinkler riser in 258-W were dated 1983 and were past due for the five-year recalibration/replacement.

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). Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 9:15 a.m., the facility did not have access to NFPA 10 (1998) for maintenance of fire extinguishers.

2. On September 20, 2011 at 9:30 a.m., the facility did not have documentation of required maintenance of fire extinguishers, including monthly inspections.

3. On September 20, 2011 at 11:19 a.m., the fire extinguisher located in the Treatment Mall by door 221-E was past due for service. This condition was also found on the extinguishers in the Entrance Corridor, 102-E, 145-W, Hobby Shop, and Rehab Therapy.

4. On September 20, 2011 at 11:43 a.m., the fire extinguisher in 253-E was mounted over 60-inches from the floor to the handle. This condition also existed in Room 155-E, and the Hobby Shop.

Based on observations and interview it was determined that the facility failed to install/maintain 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). Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 9:15 a.m., there was no current documentation of a semi-annual inspection of the kitchen hood suppression system.

2. During the facility tour on September 20, 2011 from 9:00 a.m. to 3:40 p.m., cooking stoves in the Staff Lounge, the Treatment Mall by 222-E, and 145-W were found to not be properly vented to the exterior of the building.

3. On September 20, 2011 at 1:40 p.m., the pull station for the kitchen hood suppression was installed within 10-feet of the cooking surface.

Based on observations and interview it was determined that the facility failed to prohibit the use of portable space heating devices. This resulted in the potential for ignition of nearby combustibles (LSC 19.7.8). Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 10:50 a.m., unapproved space heaters were found in 223-W and 155-W.

Based on observations, record review and interviews it was determined that the facility failed to maintain vertical opening enclosures. This resulted in the potential for spreading smoke and/or fire to other floors, exposing residents & staff to a hazardous environment (LSC 19.5.4, 8.4, 9.5, NFPA 82). Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 11:37 a.m., the laundry chute in 246-E was not properly sealed in the mortar around the chute door.

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 19.7.5.1). Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 11:26 a.m., flammable spray foam bases were found in the artificial plants by Rooms 232-E and 235-E.

Based upon observations and interviews it was determined that the facility failed to provide approved draperies, curtains, and other loosely hanging fabrics and films. This resulted in the potential for excessive fire spread (LSC 19.7.5.1). Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 1:54 p.m., the facility could not provide documentation that the curtains in the Day Room across from 129 and in the First Floor West Day Room were compliant with NFPA 701 standards.

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

1. On September 20, 2011 at 1:37 p.m., the light switch in the Oxygen Storage Room was installed within 60-inches of the floor.

2. On September 20, 2011 at 2:36 p.m., the electrical outlets in the Oxygen Storage Room 143-W were installed within 60-inches of the floor.

Based on observations and interview it was determined that the facility failed to prohibit the use of candles within the facility. This resulted in the potential for unexpected ignition source & excessive fire spread. Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 10:58 am, candles with burned wicks were found in 235-W and in the hallway of the Basement Offices.

Based on observations and interview it was determined that the facility failed to provide a safe exhaust for the dryer. This resulted in the potential for ignition of nearby combustibles. Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

2. On September 20, 2011 at 2:52 p.m., the dryer duct in the Therapy Mall was crushed.

Based on observations, record review and interviews it was determined that the facility failed to properly maintain the generator. This condition created a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient, which constitutes Immediate Jeopardy. Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 4:50 p.m., there was no documentation or evidence that the emergency generator had been tested, inspected or maintained in accordance with NFPA 110 Standard by a qualified technician. The only records on-site indicated that the generator had been tested/maintained in 4/2010, 12/2010, 4/2011 and 8/2011, but the facility could not provide any documentation that the person performing the work was qualified to do so. There was no documentation or tags that the system had ever been inspected. The Maintenance Department was reorganized in 2009, and any documentation of maintenance or inspections of the generator before that time could not be located.

2. On September 20, 2011 at 10:33 a.m., the emergency generator did not have an annunciator panel. It was also found to be missing a remote emergency shut off outside of the generator room, and the battery-powered emergency light was not working adequately and needed replaced.

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). Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 10:30 a.m., relocatable power taps were found in the Chaplain's Office in 203-C. Per interview with the Maintenance Specialist, this condition existed in all offices, including the copy room, 226-I, 227-E, 236-W and 225-E, 252-W, Day Room at the TV, 225-E, 207-C (daisy chained with an extension cord to the electronic board), Day Room at the TV across from 129, 155-W, Staff Computer Lab, at the phone system in B-120, Commissary, and in the Day Room at the TV on the first floor west wing.

2. During the facility tour on September 20, 2011 from 9:00 a.m. to 3:40 p.m., unapproved household-rated appliances were found in 223-W, 245-W, Staff Lounge, 155-W, and 116-W. Some appliances were also found to be plugged into a relocatable power tap instead of directly into an outlet.

3. On September 20, 2011 at 11:06 a.m., a 6 to 2 electrical outlet plug adapter was found at the surveillance television in 257-W.

4. On September 20, 2011 at 11:17 a.m., electrical panel "G" did not close and latch properly by 221-E.

5. On September 20, 2011 at 1:50 p.m., a broken electrical outlet cover was found in Room 129. This condition was also found by B-129.

6. On September 20, 2011 at 3:15 p.m., two open junction boxes were found in the ceiling in the Commissary.

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. Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 3:30 p.m., the facility did not have a policy for performing a fire watch if the fire sprinkler system was out of service for more than four hours, including notifying the local fire department and OSFM.

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 patients & staff to a safe refuge. Surveyor was accompanied by the Maintenance Specialist and the Staff Training and Development Coordinator who acknowledged the existence of the following conditions. Findings include, but are not limited to:

1. On September 20, 2011 at 3:30 p.m., the facility did not have a policy for performing a fire watch if the fire alarm system was out of service for more than four hours, including notifying the local fire department and OSFM.