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Based on observation and interview, the facility failed to maintain the two-hour rated, occupancy separation between the hospital and medical office/therapy building in a accordance with the requirements of NFPA 101 (2012 edition), sections 19.1.3.5 and 8.2.1.3. This deficient practice could affect all 6 patients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 06/05/2018 at 1:30 pm, observation revealed the double doors, on the lower level in the two-hour fire-rated wall between the café and dining room, did not fully close and latch, the door was held open by the door coordinator.
2. On 06/05/2018 at 3:35 pm, observation revealed the double doors, at the top of the open stair in the two-hour fire-rated wall, between the café and dining room, did not fully close and latch, the door was held open by the door coordinator.

These deficiencies were confirmed at the time of discovery by a concurrent observation and interview with Staff F.

Based on observation and interview, the facility failed to protect a hazardous areas in accordance with the requirements of NFPA 101 (2012 edition), 19.3.2.1.3. This deficient practice could affect an undetermined number of staff and visitors.

Findings include:

1. On 06/05/18 at 1:12 pm, observation revealed the material management storage room door did not self-close and latch as the door was held open by the door coordinator.

2. On 06/05/18 at 1:15 pm, observation revealed the med gas storage room door did not self-close and latch as the door was held open by the door coordinator.

3. On 06/05/18 at 1:15 pm, observation revealed the soiled linen room door did not self-close and latch as the door was held open by the door coordinator.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff F.

Based on record review and staff interview, the facility did not ensure that the fire alarm system is tested in accordance with an approved program complying with the requirements of NFPA 101 (2012 edition), Sections 19.3.4 and 9.6.1, NFPA 70, National Electric Code (2011 edition), and NFPA 72, National Fire Alarm and Signaling Code (2010 edition) Section 14.4.5.3, 14.4.5.3.1 and 14.4.5.3.2. This deficient practice could affect all 6 paitents and an undetermined number of staff and visitors.

Findings include:

On 06-05-2018 at 11:20 a.m., a review of the annual fire alarm system test/inspection report documents dated 05-08-2018 and documents dating back to the facility opening in 2016 revealed that there was no record of the smoke detectors being tested for sensitivity.

This deficient practice was confirmed at the time of discovery by a concurrent interview with staff F.

Based on observation and interview, the facility failed to install the sprinkler system in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.5, 19.3.5.3 and 9.7: NFPA 13 - 2010 edition, Section 6.7. This deficient practice could affect all 6 patients and an undetermined number of outpatients, staff and visitors.

Findings include:

On 06/05/18 at 12:46 pm, observation revealed that the post indicator valve in the sprinkler system water supply located outside of the building was not supervised by the fire alarm system.

This finding was confirmed at the time of discovery by an interview with Staff F.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 9.7.5 and NFPA 25 - 2011 edition, Sections 4.7. This deficient practice could affect an undetermined number of staff and visitors with access to the medical records office.

Findings include:

On 06/05/2018 at 1:45 pm, observation revealed in the medical records office that there were 4 sprinkler heads that had dropped away from the lay in ceiling ranging from ¼" to 1". These drops created open holes in the ceiling and did not duplicate the tight conditions that were used in the sprinkler UL certification test.

These deficiencies were confirmed at the time of discovery by a concurrent observation and interview with Staff F.

Based on observation and staff interview, the facility failed to maintain corridor doors in accordance with NFPA 101(2012 ed.) 19.3.6.3. This deficient practice could affect patients using the OR and ED suites, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 06/05/2018 at 1:20 pm observation revealed that the corridor door to the cart wash room did not latch, because the latching mechanism was missing.
2. On 06/05/2018 at 2:45 pm observation revealed that the corridor doors to Trauma 1 and Trauma 2 did not fully close and latch.
3. On 06/05/2018 at 2:51 pm observation revealed that the corridor door to the MRI storage room did not latch, because the latching mechanism was missing.
4. On 06/05/2018 at 3:09 pm observation revealed that the corridor door to OR 1 did not fully close and latch.
5. On 06/05/2018 at 3:25 pm observation revealed that the corridor door to the PACU did not fully close and latch.
6. On 06/05/2018 at 3:30 pm observation revealed that the corridor door to central sterile did not fully close and latch.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff F.

Based on record review and interview the facility failed to conduct fire drills in accordance with, the requirements of NFPA 101 - 2012 edition, Sections 4.7.1, 4.7.2, 4.7.6, 19.7.1, 19.7.1.4 and 19.7.1.6. This deficient practice could affect all 72 residents and an undetermined number of staff and visitors.

Findings include:

On 06/05/18 at 12:08pm, it was noted during review of the facility fire drills for the last 12 months that 3 of 4 1st shift drills were conducted between 10:00 am and 10:40 am, which is not varied throughout the shift. Additionally the silent drills did not include record of the transmission of the alarm single to the monitoring company.

These findings were confirmed at the time of discovery by an interview with Staff F.

Based on record review and interview, the facility failed to provide loading and testing of the emergency generator in accordance with the requirements of NFPA 101 (2012 edition), 19.5.1 and 9.1.3; and NFPA 110 (2010 edition), 8.4.2. This deficient practice could affect all 6 patients as well as an undetermined number of staff and visitors.

Findings include:

On 06/05/18 at 4:11 pm, it was noted during a review of the generator, monthly and weekly records, for the last 12 months the monthly loading did not reach at least 30% of the name plate rating.

These findings were confirmed at the time of discovery by an interview with Staff F.