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Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls to provide at least a one half hour fire resistance rating in two instances within the facility.

Findings include:

1. Observation on July 17, 2014, between 9:50 AM and 11:15 AM revealed the following smoke barrier penetrations:

a. 9:50 AM - The 2nd floor smoke barrier wall had an unsealed penetration around an electrical conduit, located in the corridor, adjacent to room #2050;

b. 11:15 AM - The 1st floor smoke barrier wall had an unsealed penetration around the top of a duct, located in the OR waiting room.

Exit interview with the facility administrator and facility representatives #1, #2, and #3, on July 17, 2014, between 11:35 AM and 11:45 AM confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier door openings in one instance, on one of two floors within the facility.

Findings include:

1. Observation on July 17, 2014, at 10:50 AM revealed the 1st floor smoke barrier doors located at the rear Clinic had a gap between the doors when in the closed position.

Exit interview with the facility administrator and facility representatives #1, #2, and #3, on July 17, 2014, between 11:35 AM and 11:45 AM confirmed the door gap.

Based on observation and interview, it was determined the facility failed to maintain one hazardous area, affecting one of two floors in this component.

Findings include:

1. Observation on July 17, 2014, at 11:10 AM, revealed the pharmacy/gift shop rear storage room door was propped open with a wooden wedge.

Exit interview with the facility administrator and facility representatives #1, #2, and #3, on July 17, 2014, between 11:35 AM and 11:45 AM confirmed the storage room door was held open with a wedge.

Based on observation, documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system, affecting the entire facility.

Findings include:

1. Review of sprinkler system testing and inspection documentation on July 17, 2014, between 10:00 AM and 10:40 AM, revealed the following deficiencies:

a. 10:00 AM - The sprinkler system fire pump had not been tested weekly under a no flow condition since the opening of the facility in December 2013.

b. 10:10 AM - The sprinkler system had not been inspected or tested on a quarterly basis since the opening of the facility in December 2013.

c. 10:40 AM - Second floor patient rooms had solid, non-meshed cubicle curtains installed, which would obstruct the sprinkler spray pattern.

Exit interview with the facility administrator and facility representatives #1, #2, and #3, on July 17, 2014, between 11:35 AM and 11:45 AM confirmed the sprinkler system was not tested as required and confirmed the 2nd floor obstructed sprinkler heads.

Based on observation and interview, it was determined the facility failed to maintain the medical vacuum system affecting two of two floors in this component.

Findings include:

1. Observation on July 17, 2014, at 10:37 AM revealed the medical vacuum pump display indicated service needed, for the vacuum pump lag and lead indicators.

Exit interview with the facility administrator and facility representatives #1, #2, and #3, on July 17, 2014, between 11:35 AM and 11:45 AM confirmed the medical vacuum pump required service and had not been repaired.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment in one instance, on one of two floors within the facility.

Findings include:

1. Observation on July 17, 2014, at 9:53 AM revealed an electrical wire was not terminated in a junction box in the 2nd floor corridor, adjacent to room 2050.

Exit interview with the facility administrator and facility representatives #1, #2, and #3, on July 17, 2014, between 11:35 AM and 11:45 AM confirmed the wire was not terminated in a junction box.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier walls to provide at least a one half hour fire resistance rating in two instances within the facility.

Findings include:

1. Observation on July 17, 2014, between 9:50 AM and 11:15 AM revealed the following smoke barrier penetrations:

a. 9:50 AM - The 2nd floor smoke barrier wall had an unsealed penetration around an electrical conduit, located in the corridor, adjacent to room #2050;

b. 11:15 AM - The 1st floor smoke barrier wall had an unsealed penetration around the top of a duct, located in the OR waiting room.

Exit interview with the facility administrator and facility representatives #1, #2, and #3, on July 17, 2014, between 11:35 AM and 11:45 AM confirmed the unsealed penetrations.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier door openings in one instance, on one of two floors within the facility.

Findings include:

1. Observation on July 17, 2014, at 10:50 AM revealed the 1st floor smoke barrier doors located at the rear Clinic had a gap between the doors when in the closed position.

Exit interview with the facility administrator and facility representatives #1, #2, and #3, on July 17, 2014, between 11:35 AM and 11:45 AM confirmed the door gap.

Based on observation and interview, it was determined the facility failed to maintain one hazardous area, affecting one of two floors in this component.

Findings include:

1. Observation on July 17, 2014, at 11:10 AM, revealed the pharmacy/gift shop rear storage room door was propped open with a wooden wedge.

Exit interview with the facility administrator and facility representatives #1, #2, and #3, on July 17, 2014, between 11:35 AM and 11:45 AM confirmed the storage room door was held open with a wedge.

Based on observation, documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system, affecting the entire facility.

Findings include:

1. Review of sprinkler system testing and inspection documentation on July 17, 2014, between 10:00 AM and 10:40 AM, revealed the following deficiencies:

a. 10:00 AM - The sprinkler system fire pump had not been tested weekly under a no flow condition since the opening of the facility in December 2013.

b. 10:10 AM - The sprinkler system had not been inspected or tested on a quarterly basis since the opening of the facility in December 2013.

c. 10:40 AM - Second floor patient rooms had solid, non-meshed cubicle curtains installed, which would obstruct the sprinkler spray pattern.

Exit interview with the facility administrator and facility representatives #1, #2, and #3, on July 17, 2014, between 11:35 AM and 11:45 AM confirmed the sprinkler system was not tested as required and confirmed the 2nd floor obstructed sprinkler heads.

Based on observation and interview, it was determined the facility failed to maintain the medical vacuum system affecting two of two floors in this component.

Findings include:

1. Observation on July 17, 2014, at 10:37 AM revealed the medical vacuum pump display indicated service needed, for the vacuum pump lag and lead indicators.

Exit interview with the facility administrator and facility representatives #1, #2, and #3, on July 17, 2014, between 11:35 AM and 11:45 AM confirmed the medical vacuum pump required service and had not been repaired.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment in one instance, on one of two floors within the facility.

Findings include:

1. Observation on July 17, 2014, at 9:53 AM revealed an electrical wire was not terminated in a junction box in the 2nd floor corridor, adjacent to room 2050.

Exit interview with the facility administrator and facility representatives #1, #2, and #3, on July 17, 2014, between 11:35 AM and 11:45 AM confirmed the wire was not terminated in a junction box.