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Based on observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to meet construction types for nonbearing walls for areas within the building. This resulted in the potential for uncontrolled smoke and heat migration into the other parts of the building in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 19.1.6.4 and 19.1.6.5).

Findings include, but were not limited to:

1. On 01/23/2019, at 9:50 a.m., there were two unsealed wall penetrations above the door within the 12th floor chiller room.

2. On 01/23/2019, at 11:00 a.m., there were two unsealed wall penetrations within the soiled utility room PRPM22.

3. On 01/24/2019, at 9:49 a.m., there were two unsealed wall penetrations in the electrical room within the pharmacy.

4. On 01/24/2019, at 1:55 p.m., there was a ceiling tile within the 6th floor Behavioral Health laundry room that has water damage and is hanging down from the ceiling exposing the unprotected portion of the ceiling.

5. On 01/24/2019, at 2:00 p.m., there were two 4 inch conduits in the data closet on the 6th floor, behavioral health department, that was not properly sealed.

Surveyor was accompanied by the Facility 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 FacilityDirector that the facility failed to install proper hold-open devices that will release on the actuation of the fire alarm system, fire sprinkler system or power loss for areas throughout the building. This resulted in the potential for smoke and fire to spread to other areas of the facility (LSC 7.2.1.8.2, 19.2.2.2.7, 19.2.2.2.8).

Findings include, but are not limited to:

During the survey conducted 01/22/2019 to 01/24/2019, there were 9 unapproved hold open devices (door wedges) being used throughout the building, including two snow shovels used to prop open a set of fire doors leading to the trash compactor.

Surveyor was accompanied by the 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 Director that the facility failed to install proper maintain components, including fire rated doors and walls in 5 of the sampled smoke compartments. This resulted in the potential for smoke and fire to spread to other areas of the facility (LSC 7.2.3, 19.2.2.2.3, 19.2.2.4).

Findings include, but are not limited to:

1. On 01/23/2019, at 11:11 a.m., the west leaf of the doors separating the two smoke compartments at 5K3C, when tested by the surveyor did not properly close and latch.

2. On 01/23/2019, at 3:19 p.m., the door separating a clean linen storage room from the corridor, when tested by the surveyor did not properly close and latch.

3. On 01/24/2019, at 10:00 a.m., the door next to IRC3, when tested by the surveyor did not properly close and latch.

Surveyor was accompanied by the Facility 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 Director that the facility failed to provide a 1-hour fire separation or an automatic fire extinguishing system between hazardous areas and the corridor for 2 of the sampled smoke compartments of the building. This resulted in the potential for residents/patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 19.3.2.1, 8.4, 8.7.1)

Findings include, but are not limited to:

1. On 01/23/2019, at 10:20 a.m., there was a door leading to a storage room (#11N241) that stored combustibles and was greater than 50 sq.ft. that did not have a door closer.

2. On 01/23/2019, at 10:48 a.m., there was a door leading to a storage room (#11N306) that stored combustibles and was greater than 50 sq.ft. that did not have a door closer.

Surveyor was accompanied by the 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 Director 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 19.3.2.5.1 - 19.3.2.5.4, 19.3.2.5.1 - 19.3.2.5.5, 9.2.3, NFPA 96, TIA 12-2, UL300).

Findings include, but were not limited to:

1. On 01/24/2019, at 10:54 a.m., the facility failed to maintain adequate cleaning of the cooking hood system on the patient dining line within the kitchen. There was noticeable grease on the hood filters and suppression head. Kitchen staff mentioned that they clean the hood once a month, but the area back by the louvers, where the grease was built up is only cleaned once every three months.

Surveyor was accompanied by the Facility Director who acknowledged the existence of the following conditions.

Based on the observations and interview during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to install and protect alcohol based hand rub (ABHR) dispensers away from sources of ignition for 3 rooms within the building. This resulted in the potential for injury to residents/patients and staff (LSC 39.3.2.6, 8.7.3.1, 42 CFR 403, 418, 460, 482, 483, and 485, NFPA 30).

Findings include, but were not limited to:

On 01/23/2019, at 2:30 p.m., there were ABHR dispensers located directly below an ignition source (light switch) in rooms 117, 210 and 216.

Surveyor was accompanied by the 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 Director that the facility failed to install fire alarm system in accordance with NFPA 72 public or private mode systems. This resulted in the potential for system and device failure/delay and panic during fire emergencies for the 2 of the sampled smoke compartments within the building (LSC 19.3.4, 19.3.4.1, 9.6, 9.6.1.8, NFPA 72, NFPA 70).

Findings include, but were not limited to:

1. On 01/24/2019, at 1:10 p.m., there was a manual pull alarm initiating device located in the imaging department next to room BR53 that was mounted approximately 65 inches from the finish floor,

2. On 01/24/2019, at 1:33 p.m., there was a manual pull alarm initiating device located in the imaging department next to room BG13 that was mounted approximately 65 inches from the finish floor,

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

Based on observation and interview during the survey, it was determined through on-going dialog with the Facility Director that the facility failed to test and maintain smoke detectors in accordance with NFPA 72 for 1 of the sampled smoke compartments facility. This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.3, NFPA 70, NFPA 72).

Findings include, but were not limited to:

On 01/23/2019, at 10:45 a.m., there were two smoke detectors located in room 11NM3 that were covered by hair bonnets during on going construction within the room.

Surveyor was accompanied by the Facility 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 Director that the facility failed to ensure the automatic sprinkler and standpipe systems were continuously maintained, inspected and tested in a reliable operating condition for areas throughout the building. This resulted in the potential for system failure during fire emergencies (LSC 19.3.5, 9.7.5, 9.7.7, 9.7.8, NFPA 25, NFPA 2001).

Findings include, but are not limited to:

1. On 01/24/2019 at 9:50 a.m., there was a light fixture in the electrical room within the pharmacy that was suspended by a wire from the sprinkler pipe.

2. On 01/24/2019 at 10:14 a.m., the fire hose located at the helipad had not been hydrotested.

3. On 01/24/2019 at 10:34 a.m., there was a sprinkler head that had paint or other foreign matter on it in room IR33.

4. On 01/24/2019 at 10:32 a.m., there was a sprinkler head located in the chapel's northeast corner that was located within 4 inches of the wall.

5. On 01/24/2019 at 10:34 a.m., there was a sprinkler head that had paint or other foreign matter on it within the foyer of the chapel.

6. On 01/24/2019 at 10:50 a.m., there were corroded sprinkler heads located within the second walk-in freezer.

7. On 01/24/2019 at 1:25 p.m., there was a sprinkler head that was located against the wall in room BR15.

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

Based on interviews and record review during the survey, it was determined through on-going dialog with the Facility Director 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:

On 01/22/2019, during record review between 3::00 p.m. and 4:30 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as but not limited to the number of simulated occupants evacuated from the affected smoke compartment, time to complete the simulated evacuation from the affected smoke compartment to an unaffected smoke compartment. Types of fires simulated were not varied.

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

Based on record review and interview during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to ensure Maintenance, Inspection & Testing - Doors, Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. This resulted in the potential for the fire doors to fail during a fire event. 39.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Findings include, but were not limited to:

On 01/23/2019, during record review between 2:00 p.m. and 2:30 p.m., there was no documentation presented to the surveyor showing the annual inspection for the Fire doors. When asked if the doors have been inspected the facility was not aware that they had any fire rated doors.

Surveyor was accompanied by the 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 Director 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:

On 01/23/2019 through 01/24/2019, there were unapproved space heating devices located within staff areas throughout the hospital. Surveyors counted approximately 15 devices.

Rooms include, but are not limited to: 1N107, 1N103, 1N107 and 1N106, 2NC23, 1N56, 1N41, 1N24, 1N07 and the main lobby reception area.

Facility staff were aware these devices were not allowed and were actively working to remove these devices from the hospital.

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