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Based on observation and staff interview, the facility failed to ensure the patient room doors within sleeping suites were smoke resistant in accordance with NFPA 101, Chapter 19.2.5.7.1.2 and 19.3.6.3.1. This had the potential to affect all patients utilizing this area of the facility. The patient census was 12.

Findings include:

Fourth floor facility tour took place on 11/13/17 with staff AA, BB and CC. Within the intensive care unit, observation of patient room doors #5 and #7 revealed they failed to close properly allowing for the passage of smoke.

This finding was verified in an interview by all staff present during tour.

Based on observation and staff interview, the facility failed to ensure all hazardous room doors were equipped with a self-closing device as required by NFPA 101 Chapter 39.3.2 and 8.7. This had the potential to affect all patients utilizing this facility. The facility census was 189.

Findings include:

A facility tour of this offsite physical therapy building took place on the morning of 11/15/17 with staff AA, BB and CC. During tour of the hazardous storage room, observation was made of the door lacking a self-closing device.

This finding was verified in an interview by all staff present during tour.

Based on observation and staff interview, the facility failed to ensure all emergency lights were maintained according to NFPA 101, Chapter 39.2.9 and 7.9 and 4.6.12.3. This had the potential to affect all patients utilizing this facility. The facility census was 189.

Findings include:

A facility tour of this offsite physical therapy building took place on the morning of 11/15/17 with staff AA, BB and CC. During tour of the center core, emergency light number 20016 was tested and found to be non-functioning.

This finding was verified in an interview by all staff present during tour.

Based on observation and staff interview, the facility failed to ensure all exit signs were illuminated properly according to NFPA 101, Chapter 19. This had the potential to affect all patients utilizing this area of the facility. The patient census was 12.

Findings include:

First floor facility tour took place on 11/14/17 with staff AA, BB, CC and DD. During tour of room 1411 of the non-sleeping suite, observation was made of an exit sign that failed to be illuminated as required.

This finding was verified in an interview by all staff present during tour of this area of the facility.

Based on observation and staff interview, the facility failed to ensure vertical openings were protected with at least a two hour fire rating in regard to doors properly closing and latching shut according to NFPA 101, Chapter 19.3.1 and 8.6. This had the potential to affect patients utilizing this area of the facility. The patient census was 12.

Findings include:

First floor facility tour took place on 11/14/17 with staff AA, BB, CC and DD. Within the corridor between the kitchen and lobby at stairwell #3, observation was made of stairwell door #3 failing to close and latch properly.

This finding verified in an interview by all staff present during tour.

Based on observation and staff interview, the facility failed to ensure the cleaning storage room door was able to close and latch properly in accordance with NFPA 101, Chapter 19.3.2. This had the potential to affect patients utilizing this area of the facility. The patient census was 12.

Findings include:

Fourth floor facility tour took place on 11/13/17 with staff AA, BB and CC. Within the post anesthesia care unit, observation was made of the bio-hazard cleaning room #4021 having a bio-hazard bag stuffed in the door latch catch preventing the door latch from properly engaging into the door latch catch.

This finding was verified in an interview by all staff present during tour.

Based on documentation review and staff interview, the facility failed to ensure all smoke detectors were sensitivity tested according to NFPA 101 Chapter 39.3.4 and 9.6 and 4.6.12.3. This had the potential to affect all patients utilizing this facility. The facility census was 189.

Findings include:

The fire alarm system documentation review took place on 11/16/17 with staff AA, BB and CC. During review, the records did not reveal the smoke detectors had been sensitivity tested.

In an interview, Staff AA and BB revealed they contacted the company who performed the annual testing of the fire alarm system and verified that there was no sensitivity testing of the smoke detectors.

Based on observation and staff interview, the facility failed to install the sprinkler system in order to protect all required areas according to NFPA 13 and 25. This had the potential to affect patients utilizing this area of the facility. The patient census was 12.

Findings include:

First floor facility tour took place on 11/14/17 with staff AA, BB, CC and DD. During tour of the kitchen, observation was made of no sprinkler heads within the refrigerator/freezer unit.

This was verified in an interview by all staff present during tour of the kitchen area.

Based on review of the facility floor plans, observation, and staff interview, the facility failed to ensure the smoke barrier was constructed to resist smoke for at least one hour as documented on the facility floor plans. This had the potential to affect patients utilizing these areas of the facility. The patient census was 12.

Findings include:

Facility tour began on the fourth floor the morning of 11/13/17 with staff members AA, BB, CC and DD. During tour of the building's smoke/fire barriers, observation was made of penetrations above the ceiling tiles in the following areas:

Fourth floor:

1) Within the intensive care unit at room 4061, observation was made of two open end conduits, one yellow and the other silver. Additionally, observation was made of two silver conduits that lacked fire sealant around the annular space and the top of the drywall where it met the upper deck was noted to have an open gap along the top edge the length of the drywall.

2) Within the southeast corner of the surgery department located between operating room #2 and a storage room and facing the portion of the smoke barrier wall of which the smoke barrier door was attached to the opposite side, observation was made of an unsealed silver conduit, an approximate 18 inch by four inch rectangle opening with gray and tan wires passing through, and an approximate ten inch by three inch opening with gray wires passing through.

Third floor:

3) In the northeast corner of the family birth center from the corridor side of room 3030, observation was made of an open end conduit near a smoke damper.

4) Within the center corridor smoke barrier located in the family birth center between the nursery and the female staff room, observation was made of unsealed blue wires passing through the smoke barrier.

5) Facing the smoke barrier within the nursery, observation was made of an approximate two inch conduit in which the fire sealant had fallen out.

6) Within room #1 of the family birth center, an approximate eight foot section by an undetermined depth of drywall was missing from the smoke barrier. Additionally, to the right of this missing section of drywall, an approximate two foot section of drywall was missing.

Second floor:

7) Within the east wing of the floor and within the room bordering the east side of the center stairwell, observation was made of an open end conduit with yellow and white wires passing through.

8) Following the smoke barrier south of the corridor and within a room bordering the east side of the smoke barrier, observation was made of an approximate seven foot section of drywall missing.

First floor:

9) Facing the smoke barrier at the electrical room door nearest the morgue, observation was made of one penetration with blue and white wires and a sprinkler pipe that was not sealed around the annular space.

10) Following the smoke barrier around to the open area south of the electrical room, observation was made of two, one to two inch holes, and two silver conduits (approximately one inch and four inches) not sealed around the annular space.

11) At the center door of the center of the smoke barrier separating the two large non-sleeping suites, observation was made of an unsealed one and a half inch silver conduit and a four inch duct not sealed around the annular space.

These findings were verified in an interview by staff AA during the facility tour.

Based on observation and staff interview, the facility failed to ensure the smoke barrier doors closed properly to resist the passage of smoke according to NFPA 101 Chapter 19. This had the potential to affect all those utilizing this facility. The patient census was 12.

Findings include:

Facility tour took place on 11/13/17 and 11/14/17 with staff AA, BB, CC, and DD. During tour, observation was made of smoke barrier doors that were noted to have gaps between the door leafs greater than one eighth inch when in the closed position at the following locations:

1) First floor snack bar (both sets) double doors. Additionally, facing the doors from the outside of the snack bar, the left set failed to latch shut.

2) Third floor smoke/fire barrier doors separating 3 West patient care from the family birth center.

3) Fourth floor smoke/fire barrier doors separating 4 West from the intensive care unit.

These findings were verified in an interview by the staff present during the tour.

Based on fire drill documentation review and staff interview, the facility failed to ensure there was documentation of the transmission times of the activated pull station device with each fire drill conducted according to NFPA 101 Chapter 19.7.1. This had the potential to affect all patients utilizing this facility. The patient census was 12.

Findings include:

Fire drill documentation review took place on 11/13/17 with staff BB and CC. During review it was noted the records lacked the transmission time of the activated pull station device. When staff BB was questioned about having any documentation of transmission times, he/she stated they had not been documenting those times with the fire drills.

Based on observation and staff interview, the facility failed to install the required remote annunciator panel for each generator according to NFPA 99. This had the potential to affect patients utilizing this facility. The patient census was 12.

Findings include:

First floor facility tour took place on 11/14/17 with staff AA, BB, CC and DD. During tour of the room which housed all of the building systems' components, observation was made of no remote annunciator panel for the generators. When questioned if they had a remote annunciator panel, staff AA stated that it was computerized and monitored through the computer system. In review of the computer system, it was noted that the computer only monitored when the generator was running and when the fuel was low. All other required components of the generators were not being monitored.

This finding was verified in an interview with the staff present during tour.