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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 sections of the health care facility (LSC 9.7, 19.1.3.3, 42 CFR 482.41 & 485.623).

Findings include, but are not limited to:

On 03/06/18, at 9:50 a.m., there was a 90-minute fire rated door within the fire barrier seperating Suite 100 and the patient waiting area that did not close and latch properly when tested by the surveyor.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions during interview at the tiime of the observation.

Based on observations and interview, it was determined that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections unless modified by 19.2.2 through 19.2.11. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10.1).

Findings include, but are not limited to:

During survey conducted on 03/06/18 at approximately 11:00 a.m., it was observed that there were several kitchen carts that were being stored in the corridor going from the main kitchen located on the maintenance floor.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions during interviews at the time of observation.

Based on observations and interview, it was determined that the facility failed to install proper hold-open devices that will release on the actuation of the fire alarm or fire sprinkler system. This resulted in the potential for smoke and fire to spread to other areas of the facility (LSC 19.2.2.3).

Findings include, but are not limited to:

During the survey dates of 03/06/18 through 03/08/18 there were observations of 12 unapproved hold open devices observed by the surveyor being used or located at doors with self-closing devices meant to close upon activation of the fire alarm.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions during interviews at time of observation.

Based on observations and interview it was determined that the facility failed to maintain adequate discharge from building exits in accordance with 7.7. This resulted in the potential for panic and injury to residents/patients & staff during emergency evacuations and relocation for one exit discharges of the building (LSC 19.2.7 and S&C 05-38).

Findings include, but were not limited to:

On 03/07/18, at 4:05 p.m., there was an exit discharge located at the critical care north exit that discharged to a fenced off construction area that blocked the access to the public way and the path to an identified area of refuge from the same exit was also blocked by construction material.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions during the interview at the time of observation.

Based on observations and interview it was determined that the facility failed to properly identify exits of the building. This resulted in the potential for panic and confusion during an evacuation (LSC 19.2.10, 7.10).

Findings include, but were not limited to:

On 03/08/18, at 6:10 a.m., there was an exit sign observed at the WP3 stairwell that did not clearly identify the intended exit. The sign was located as such that an adjacent door leading outside could be mistaken as an exit discharging into a gravel area that would not allow for wheeled equipment to reach the public way.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions during interviews at the time of observation.

Based on the observations and interview it was determined that the facility failed to install and protect alcohol based hand rub (ABHR) dispensers away from sources of ignition for universe of the building. This resulted in the potential for injury to residents/patients and staff (LSC 19.3.2.6, 8.7.3.1, 42 CFR 403, 418, 460, 482, 483, and 485, NFPA 30).

Findings include, but were not limited to:

During the survey dates of 03/06/18 through 03/08/18, it was observed by the surveyor that in 16 locations throughout the main hospital there were ABHR dispensers that were located within one inch of an ignition source.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions during interviews at the time of observation.

Based on observations and interview it was determined that the facility failed to maintain fire alarm control functions and an alternative power supply in accordance of NFPA 72. This resulted in the potential for system failure/delay and panic during fire emergencies for the entire building (LSC 19.3.4.4, 9.6.1, 9.6.5, and NFPA 72).

Findings include, but were not limited to:

1. On 03/07/18, at 12:11 p.m., the Fire Alarm remote alarm indicator located at the east nurses station 8th floor was observed reading a trouble signal and identifying a network failure, which indicates a potential failure for the alarm system functioning properly.

2. On 03/07/18, at 12:19 p.m., the Fire Alarm remote alarm indicator located at the west nurses station 8th floor did not have power, which indicates a potential failure for the alarm system functioning properly.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions during interviews at the time of the observation.

Based on observations and interview it was determined that the facility failed to ensure that the facility was protected throughout by an approved automatic sprinkler system in accordance with NFPA 13 for 4 electrical closets of the building. This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 19.3.5, 19.3.5.1 - 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1), and NFPA 13).

Findings include, but were not limited to:

Observation during the survey revealed (4) west side telecom closets located on floors 6-9 of the main tower were missing the required sprinkler coverage. For example: on 03/0718, at 9:30 a.m. near the west side nurses station on the 9th floor; on 03/07/18, at 10:00 a.m. near the west side nurses station on the 8th floor; on 03/07/18, at 10:30 a.m. near the west side nurses station on the 7th floor; on 03/07/18, at 11:45 a.m. near the west side nurses station on the 6th floor.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions during interviews at the time of the observation.

Based on observations and interview it was determined that the facility failed to select, install, inspect and maintain fire extinguishers in accordance with adopted standards for construction areas within the building. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.12, NFPA 10).

Findings include, but were not limited to:

1. During the survey dates of 03/06/18 through 03/08/18, it was observed in areas where construction was being performed there were portable fire extinguishers provided and in those areas the extinguishers were place on the floor and not properly mounted no less than 4 inches off the floor.

2. On 03/08/18, at 8:33 a.m., there was a fire extinguisher located in the Fire Control Center that had not received a monthly visual inspection for the past 3 months, as indicated on the fire extinguisher tag.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions during interviews at the time of observations.

Based on interviews and record review it was determined 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 19.7.1.4 -19.7.1.7).

Findings include, but were not limited to:

Review of the fire drill documentation for the previous 12 months reflected that fire drills were not conducted under varying conditions as evidence by the following:

1. On 03/05/18, the fire drill reflected all but 2 drills performed in the previous 12 months simulated 1 person being moved; on 03/05/18, the fire drill reflected all but 2 drills performed in the previous 12 months simulated a trash can fire; on 03/05/18, the fire drill reflected all but 2 drills performed in the previous 12 months had comments of "drill performed".

2. On 03/07/18, at 3:00 p.m., it was observed that a code red was announced over the intercom for the smell of smoke coming from the elevator shaft. Staff responded by going to the announced location, however the fire alarm was never manually activated.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions during interviews at the time of the observation during interview at the time of the observations.

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).

Findings include, but were not limited to:

During survey dates of 03/06/18 through 03/08/18, it was observed that there were oil heated space heating appliances being used in staff office areas in the main tower that, when tested, reached a surface temperature exceeding 212 degrees. Three sampled heaters reached temps of up to 230 degrees and there were two different manufacturers of the same style heater and each were tested and exceeded the 212 degrees.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions during interview at the time of the observation.

Based on observations, record review and interviews it was determined through on-going dialog with the Maintenance Director that the facility failed to properly maintain the generator or other alternate power source and associated equipment affecting the entire facility. This resulted in the potential for the lack of emergency electrical power during an emergency event (LSC 19.5, 9.1.2, NFPA 99, NFPA 70, and NFPA 111).

Findings include, but were not limited to:

On 03/08/18, at 6:30 a.m. there were ladders stored up against the electrical panels the electrical closets located near OR CVL5. This was also an observation in other electrical closets located throughout the hospital.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interview it was determined that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to patients & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8).

Findings include, but are not limited to:

1. During survey dates of 03/06/18 through 03/08/18, it was observed on floors 4, 6, 7, 8 and 9 in the main tower that the Relocateable Power Taps (RPT) being used were found to be placed on the floor at their locations.

2. On 03/07/18, at 4:15 p.m., there was an open electrical junction box that exposed potentially energized wiring located under the stair landing of the main mechanical room.

3. On 03/07/18, at 4:30 p.m., there was an open electrical junction box that exposed potentially energized wiring located in the area of MT 9603.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions during interview at the time of the observation.

Based on observations and interviews it was determined 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 in universe. (LSC 19.3.2.4, NFPA 99 5.1.3.2.4).

Findings include, but were not limited to:

1. On 03/06/18, at 11:40 a.m., there was flammable gases, in the form of (4) 5 gallon propane cylinders located within an enclosed propane storage cage that was located in a room storing oxygen cylinders at amounts greater than 300 cubic feet and less than 3,000 cubic feet.

2. On 03/07/18, at 3:30 p.m., there was a room located on the 2nd floor clean utility room in IRU that was being used to store oxidizing gases that had electrical outlets and/or switches that were less than 60'' off the floor and did not have the proper impact protection.

Surveyor was accompanied by the Maintenance Director who acknowledged the existence of these conditions during interview at the time of the observation.