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Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with LSC 9.6.1.3, failed to maintain 1 of 1 automatic sprinkler systems, failed to ensure 1 of 1 storage corridor doors on the third floor was provided with a means suitable for keeping the door closed, had no impediment to closing, latching and would resist the passage of smoke, failed to ensure penetrations through 1 of 1 smoke barrier wall was protected to maintain the smoke resistance of each smoke barrier, failed to ensure 1 of 6 sets of barrier doors in the basement area would restrict the movement of smoke for at least 20 minutes. , and failed to ensure 9 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills for the last 4 quarters.

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe environment.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with LSC 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, Section 14.2.1.2.2 requires that system defects and malfunctions shall be corrected, failed to maintain 1 of 1 automatic sprinkler systems. LSC 9.7.5 requires all sprinkler systems shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 Edition, Section 4.1.4.1 states the property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test and maintenance required by this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request, failed to ensure 1 of 1 storage corridor doors on the third floor was provided with a means suitable for keeping the door closed, had no impediment to closing, latching and would resist the passage of smoke, failed to ensure penetrations through 1 of 1 smoke barrier wall was protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.5 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. LSC Section 8.5.2.1 requires smoke barriers to be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. 8.5.6.2 requires penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the movement of smoke, failed to ensure 1 of 6 sets of barrier doors in the basement area would restrict the movement of smoke for at least 20 minutes. LSC 19.3.7.8 requires doors in smoke barriers shall comply with LSC Section 8.5.4. LSC 8.5.4.1 requires doors in smoke barrier shall close the opening leaving only the minimum clearance necessary for proper operation, and failed to ensure 9 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills for the last 4 quarters. LSC 19.7.1.4 requires fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

Findings include:

Based on observations with the Maintenance Supervisor between 09:37 a.m. and 2:34 p.m., the fire alarm control panel had a trouble notification illuminated on the main fire panel. The panel stated listed the trouble as "1FL FSD OR CORR O/S SUB-STER." Based on interview at the time of observation, the Maintenance Supervisor stated that an actuator for a fire/smoke damper in the sub-sterile room of the operating room was bad and has been awaiting parts to fix the device. Paperwork had been obtained from the facility indicating both the facility and alarm company know about the aforementioned condition. The Maintenance Supervisor later confirmed that the panel is still in trouble and the device still has not been fixed.

Based on review of the facility's quarterly sprinkler system inspection reports on 11/13/23 at 10:10 a.m. with the Maintenance Supervisor present, the quarterly sprinkler report dated 09/19/23 stated "Anti-freeze tested and indicate correct freeze points in the system - FAIL". When asked if he could show documentation that they had the anti-freeze added to the system, the Maintenance Supervisor stated that they had not seen that item on the aforementioned sprinkler system inspection. Based on further interview at the time of record review, the Maintenance Supervisor stated the anti-freeze has not yet been replaced.

Based on observation and interview, the facility failed to maintain the ceiling construction of 1 of 1 CT rooms. The ceiling tiles trap hot air and gases around the sprinkler and cause the sprinkler to operate at a specified temperature. NFPA 13, 2010 edition, 8.5.4.11 states the distance between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction.

Based on observations during a tour of the facility with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., the suspended ceiling of the CT room had a ceiling tile with an approximately four inch hole around a machine that had a pipe running through the ceiling which can lead to a potential delayed response to the nearby sprinkler head. Based on interview at the time of observation, the Maintenance Director stated that the hole does have an escutcheon plate to fill in the space of the ceiling tile, however the plate had slid down the pipe and left the ceiling above the tile exposed. The Maintenance Director confirmed the aforementioned issues.

Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems were provided with spare sprinklers, a spare sprinkler cabinet large enough to fit all spare sprinkler heads, and a sprinkler wrench on the premises. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.4 states a supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have been operated or damaged in any way can be promptly replaced. The sprinklers shall correspond to the types and temperature ratings of the sprinklers on the property. The sprinklers shall be kept in a cabinet located where the temperature in which they are subjected will at no time exceed 100 degrees Fahrenheit. A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers.

Based on observation with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., the spare sprinkler cabinets in the riser room were not large enough to contain all sprinkler heads and prevent damage to the sprinkler heads. When the cabinet in riser room was opened, the cabinet contained more sprinkler heads than spots available. Approximately twenty sprinkler heads were unsecured on-top and inside of the sprinkler cabinets. Based on interview at the time of the observations, the Maintenance Supervisor agreed the two cabinets were not large enough to contain all spare sprinkler heads.

Based on observation with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., the storage double doors across from the third floor nurses station did not latch. The inactive leaf of the door set had a latching device, however when closed, the door would not self-latch or engage after testing three times. Based on interview at the time of observation, the Maintenance Supervisor stated that they were unaware of the issue and agreed the inactive door did not self-latch. The latch was fixed during the survey.

Based on observation and interview, the facility failed to ensure 1 of over 100 corridor doors were provided with a means suitable for keeping the door closed, had no impediment to closing, latching, and would resist the passage of smoke. This deficient practice could affect as many as 4 staff.


Based on observations made with the Maintenance Supervisor during a tour of the facility at 3:04 p.m. on 12/13/23, the corridor door for the Oncology Suite in the basement had a self-closing device on the corridor door. This door was propped in the open position with flip down door wedge. Based on interview at the time of observation, the Maintenance Director acknowledged the aforementioned corridor door to a patient care area was propped and held in the fully open position with a flip down door wedge.

Based on observations with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., above the drop ceiling of the smoke wall separating the old OB wing and the old Alternacare dining room had an approximate half inch gap around conduit that was run through the fire/smoke wall. Based on interview at the time of observation, the Maintenance Supervisor agreed there where unsealed penetrations in the smoke barriers and would seal up the penetrations.

Based on observations made with the Maintenance Supervisor during a tour of the facility at 2:56 p.m. on 12/13/23, the set of barrier doors leading to "the old addition" or door set #056272 did not close completely due to air pressure from one side of the doors. There was a one-inch gap between the doors when closed to their fullest. Based on interview during the time of observations, the Maintenance Supervisor acknowledged these smoke barrier doors did not close completely due to air pressure pushing one door slightly open and added that he would adjust the self-closing devices to make sure that they closed fully in an emergency situation.

Based on record review of the facility's fire drill document entitled "Fire Drill Report" with the Maintenance Supervisor present, the documentation for the drills for January 2023 through September of 2023 lacked verification of the transmission of the signal for drills. Based on interview at the time of record review, the Maintenance Supervisor stated that he would advise the Security Department to request from the monitoring company confirmation of the signal being received during his fire drills.