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Based on observation and interview, the facility has failed to maintain the 2-hour fire separation at the required locations. This deficient practice could affect the safety of all residents, staff and visitors in the event of a fire, as fire and smoke could pass from one building to the other.

Findings include:

On facility tour between 08:30 AM and 1:30 PM on 08-14-2014, it was observed that the 90 minute fire separation doors in the 2 hour fire wal into the 1959 building did not operate as required in the following locations:

1) 3rd floor - 90 minute fire doors in the 2 hour fire separation wall between the 1959 building and 2007 building by room 3127 are not labeled and the doors do not latch into the floor.

2) 2nd floor - 3 hour labeled fire doors in the 2 hour fire separation wall between the 1959 building and 2007 building by room 2132 do not latch into the floor, and the leading edge of the doors when closed have a 1/2 inch gap between doors.

3) 1st floor - 3 hour labeled fire doors in the 2 hour fire separation wall between the 1959 building and 2007 building by the East elevators do not latch into the floor.

4) 1st floor - 90 minute fire doors in the 2 hour fire separation wall from the hospital corridor to the clinic corridor do not latch into the floor.

These deficiencies were verified by the Facility Consultant (JR) at the time of discovery.

Based on observation and interview it was revealed that the automatic fire sprinkler system is not in installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems (1999 edition). This deficient practice could negatively impact all the residents, visitors and staff.

Findings include:
On facility tour between 08:30 AM and 1:30 PM on 08-14-2014, it was it was revealed that facility staff could not determine if the elevator pit was equipped with an automatic fire sprinkler head.

This deficiency was verified by the Facility Consultant (JR) at the time of discovery.

Smoke detectors are required in sleeping rooms according to LSC(00) Sections 6.1.14 and 26.3.3.5.

Based on observation and interview, automatic smoke detection was not installed as required in the staff on-call sleeping room. This deficient practice could affect the safety of any staff sleeping in these rooms.

Findings include:
On facility tour between 08:30 AM and 1:30 PM on 08-14-2014, it was observed that the staff on-call sleeping room 1247 located in the Emergency Dept., did not have a system smoke detector connected the fire alarm system.

This deficiency was verified by the Facility Consultant (JR) at the time of discovery.