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Based on observations and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to install fire alarm system in accordance with LSC 19..5.2.3 (2) (f) for the entire building. This resulted in the potential for system and device failure during fire emergencies.

Findings include, but were not limited to:
On 8/15/2017, at 1312 hours, a natural gas fireplace was in use within a single patient smoke compartment without a supervised carbom monoxide monitoring device present.

This Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of these conditions.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition. This resulted in the potential for system failure during fire emergencies.

Findings include, but are not limited to:
1. On 8/14/17, during record review between 1400 and 1605 hours, weekly, monthly, and quarterly testing and maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the sprinklers and staff did not have access to the adopted 2011 edition of NFPA 25 standards.
2. On 8/14/17, during record review between 1400 and 1605 hours, documentation provided to the surveyor for the facilities required annual inspection showed outstanding deficiencies that the facility failed to correct in a timely manner.
3. On 8/15/17, at 0932 hours, the 2.5" hose connections on the Fire Department Connection were found to be in inoperable condition.
4. On 8/15/17, at 0933 hours, the FDC was found to be lacking approved informational signage.
5. On 8/15/17, at 1315 hours, a leaking fire sprinkler head was found in room 1068.
6. On 8/15/17, at 1332 hours, a leaking fire sprinkler head was found in room 1014.
7. On 8/15/17, at 131336 hours, loaded fire sprinkler heads were found in the Emergency Department Waiting Area.

This Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to maintain approved smoke barrier doors of the building. This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 20.3.7.2).

Findings include, but are not limited to:
On 8/15/2017, at 1311 hours, the smoke barrier door at room 1065 was not closing or latching properly.

This Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to properly install building service equipment for the entire facility. This resulted in the potential for a major gas leak and an unexpected fire.

Findings include, but are not limited to:
On 8/15/17, at 0918 hours, the main natural gas line supplying the entire facility was found to not be properly protected against vehicle impact, and is in close proximity to a marked vehicle parking space.
On 8/15/17, at 0936 hours, a combustible waste basket was found directly under an electrical service panel in the coffee shop.

This Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with the Facility Administrator and 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 18/19.2.9, 7.9, NFPA 110, NFPA 99, NFPA 70, and NFPA 111).

Findings include, but were not limited to:
On 8/15/2017, at 1301 hours, the facility's ATS failed to switch within the allotted 10-second timeframe.

This Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 throughout the entire facility (systemic issue). This resulted in the potential for injury to residents & staff (LSC 9.1.2, NFPA 99 10.2.3.6, 10.2.4, NFPA 70, TIA 12-5).

* Findings include, but were not limited to:
1. On 8/15/17, at 0935 hours, an unapproved RPT was found on the floor in the Founders Room.
2. On 8/15/17, at 0941 hours, an unapproved RPT was found on the floor in the Conference Room.
3. On 8/15/17, at 0947 & 0948 hours, unapproved RPT's were found on the floor in rooms 1126 & 1129.
4. On 8/15/17, at 1029 hours, an unapproved RPT was permanently affixed to the building in room 2120.
5. On 8/15/17, at 1250 hours, an unapproved RPT was permanently affixed to the building in room 1092.
* This is a systemic issue throughout the hospital.

This Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to provide safe storage (design, construction and/or ventilation) for compressed gas in (3) different rooms and/or areas of the facility. This resulted in the potential for injury to staff and patients from a damaged compressed gas cylinder releasing unexpectedly.

Findings include, but were not limited to:
1. On 8/15/17, at 0959 hours, an unsupervised oxygen cylinder was found in room 1146.
2. On 8/15/17, at 1010 hours, an unsupervised oxygen cylinder was found in room 1153.
3. On 8/15/17, at 1113 hours, an unsupervised oxygen cylinder was found in room 1095.

This Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of these conditions.