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Based on observation and interview, the facility failed to provide doors in the means of egress that unlatch with 15 pounds of force or less in accordance with the requirements of NFPA 101 (2012 edition), 7.1, 7.2.1.4.5, and 19.2.1. This deficient practice could affect all patients in the emergency suite as well as an undetermined number of staff and visitors.

Findings include:

On 4/9/18 at 1:54 pm, observation on the 1st floor in the emergency suite revealed both south exit doors from the emergency suite were mag-locked. Further observation and interview with Staff G & H revealed the door sensors were covered-up with tape, preventing the sensors from functioning and allowing the doors to open.

This deficient practice was confirmed by facility Staff G & H at the time of discovery.

Based on observation and interview, the facility failed to maintain a vertical opening enclosure with fire-stopped floor penetrations in accordance with NFPA 101 (2012 edition), 19.3.1.1 through 19.3.1.6. This deficient practice could affect all 13 patients as well as an undetermined number of staff and visitors.

Findings include:

On 4/9/18 at 12:20 pm, observation on the ground floor in the sprinkler riser room revealed two 3 inch diameter holes cored in the concrete ceiling/floor assembly with 2 inch diameter iron pipe penetrations with a 1/2 inch annual gap around the perimeter with no firestopping.

This deficient practice was confirmed with facility Staff G & H at the time of discovery.

Based on observation and interview, the facility failed to provide self-closing doors with a functioning sequencer/coordinator and an astragal to provide separation between hazardous areas and other spaces in accordance with NFPA 101 (2012 edition), Sections 19.3.2.1.2, 19.3.2.1.5(7), 8.4.3.5 and 7.2.1.8. These deficient practices could affect 3 of the 13 patiens as well as an undetermined number of staff and visitors.

Findings include:

1. On 4/9/18 at 2:08 pm, observation on the 2nd floor in the Clean Utility Room located in the 2G smoke compartment revealed a hazardous storage room greater than 50 square feet with combustible storage. A pair of double doors to the corridor had a non-functioning sequencer/coordinator to ensure the doors closed in the proper sequence to provide for full closure and positive latching. The active door latched into the inactive door leaf which was outfitted with an automatic flush bolt. The doors also had a 3/16 inch by 82 inch gap at the leading door edge with no astragal.

2. On 4/9/18 at 2:21 pm, observation on the 2nd floor in the OB Storage Room located in the 2F smoke compartment revealed a hazardous storage room with a pair of double doors on the corridor with a 3/8 inch by 82 inch gap at the leading door edge with no astragal.

These deficient practices were confirmed by faciltiy Staff G & H at the time of discovery.

Based on observation and interview, the facility failed to provide a fire alarm system in accordance with the requirements of NFPA 101 (2012 edition), 19.3.4 and 9.6 and NFPA 72 (2010 edition), 17.7.4.1 and 17.7.5.6.5.2. These deficient practices could affect all of the 13 patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 4/9/18 at 11:28 am, observation on the ground floor smoke compartment revealed the Boiler Room corridor door was held open with a mag hold-open with no smoke detection on the room side.
2. On 4/9/18 at 1:10 pm, observation on the 3rd floor in the Sterile Supply Room located in the 3B smoke compartment revealed a ceiling-mounted smoke detector located 15 inches edge-edge horizontally from a 2 foot by 2 foot air diffuser.
3. On 4/9/18 at 1:41 pm, observation on the 1st floor in the MRI Room corridor located in the 1G smoke compartment revealed a ceiling-mounted smoke detector located 17 inches edge-edge horizontally from a 1 foot by 1 foot air diffuser.

These deficient practices were confirmed by facility Staff G & H at the time of discovery.

Based on record review and interview, the facility failed to provide correct contact information for the Department of Health Services (DHS), Division of Quality Assurance (DQA) when the fire alarm system is out of service for more than 4 hours in a 24-hour period as required by NFPA 101 (2012 edition), 9.6.1.6. This deficient practice could affect all 13 patients as well as an undetermined number of staff and visitors.

Findings include:

On 4/9/18 at 10:32 am, review of the record titled "Fire Watch Plan for Fire Alarm System Failure, ADM-079" revealed the procedure addressing when the fire alarm system was out of service for more than 4 hours in a 24-hour period did not have the proper contact number for DHS, DQA of 920.448.5255. The 920.983.3200 number provided is no longer in service and has been disconnected.

This deficient practice was confirmed by facility Staff G & H at the time of discovery.

Based on observation and interview, the facility failed to provide an unobstructed sprinkler system installation in accordance with NFPA 101 (2012 edition), 19.3.5 and 9.7; and NFPA 13 (2010 edition), 8.6.5.2.1.2. This deficient practice could affect none of the patients, but an undetermined number of staff and visitors.

Findings include:

On 4/9/18 at 12:14 pm, observation in the Material Management and Purchasing Room located in the ground floor smoke compartment revealed a total of four pendant sprinkler heads obstructed by light fixtures. The sprinklers were located 6 inches from the center of the head to the edge of the light fixture, with the light fixtures projecting 3 inches off the ceiling and 2 inches lower than the adjacent sprinkler head deflectors.

This deficient practice was confirmed by facility Staff G & H at the time of discovery.

Based on record review and interview; the facility failed to inspect, test and maintain its automatic sprinkler system in accordance with NFPA 101 (2012 edition), 19.3.5 and 9.7 and NFPA 25 (2011 edition), 4.4, 5.1, 5.2.1.1, 13.1 and Tables 5.1.1.2 and 13.1.1.2. These deficient practices could affect all 13 patients as well as an undetermined number of staff and visitors.

Findings include:

1. On 4/9/18 at 10:43 am, review of facility quarterly and annual sprinkler inspection and testing reports revealed quarterly sprinkler inspection and testing dates exceeded the allowable timeframe. Report dates and types were as follows: 3/14/17 (quarterly), 5/17/17 (quarterly), 8/30/17 (quarterly), 10/3/17 (annual) and 2/27/18 (quarterly).
2. On 4/9/18 at 1:34 pm, observation on the first floor in the IT closet located in the 1F smoke compartment revealed 4 missing ceiling tiles in the drop ceiling adjacent to and on the same level as a pendant sprinkler head, exposing large voids above the drop ceiling. Each missing tile was 9 inches by 24 inches in size.

These deficient practices were confirmed by facility Staff G & H at the time of discovery.

Based on record review and interview, the facility failed to provide correct contact information for the Department of Health Services (DHS), Division of Quality Assurance (DQA) when the sprinkler system is out of service for more than 10 hours in a 24-hour period as required by NFPA 101 (2012 edition), 19.3.5.1 and 9.7.5; and NFPA 25 (2011 edition), 15.5.2. This deficient practice could affect all 13 patient as well as an undetermined number of staff and visitors.

Findings include:

On 4/9/18 at 10:58 am, review of the record titled "Fire Watch Plan for Sprinkler System Failure, ADM-080" revealed the procedure addressing when the sprinkler system was out of service for more than 10 hours in a 24-hour period did not have the proper contact number for DHS, DQA of 920.448.5255. The 920.983.3200 number provided is no longer in service and has been disconnected.

This deficient practice was confirmed by facility Staff G & H at the time of discovery.

Based on record review and interview, the facility failed to provide inspection of portable fire extinguishers at a minimum of 30-day intervals in accordance with NFPA 101 (2012 edition), 19.3.5.12 and 9.7.4.1; and NFPA 10 (2010 edition), 7.2.1.2 This deficient practice could affect all 13 patients as well as an undetermined number of staff and visitors.

Findings include:

On 4/9/18 at 10:43 am, record review of facility documents titled "Inspection of Portable Fire Extinguishers" for 2017 and 2018 revealed portable fire extinguisher 30-day inspection intervals were exceeded. The records revealed the following inspection dates: 1/12/17, 2/7/17, 3/18/17, 4/22/17, 5/19/17, 6/20/17, 7/21/17, 8/20/17, 9/16/17, 10/21/17, 11/21/17 and 12/28/17.

This deficient practice was confirmed by facility Staff G & H at the time of discovery.

Based on observation and interview, the facility failed to provide corridor spaces separated by corridor walls and doors that meet the requirements of NFPA 101 (2012 edition), 19.3.6.1, 19.3.6.2 and 19.3.6.3. This deficient practice could affect approximately 3 of the 13 patients as well as an undetermined number of staff and visitors.

Findings include:

On 4/9/18 at 2:16 pm, observation on the 2nd floor in the Kitchenette located in the 2G smoke compartment revealed that the room was not separated from the exit egress corridor by wall or door construction. The area did not satisfy all of the requirements for an exception for spaces open to the corridor. The space did not have a smoke detector, nor was it arranged and located to allow direct supervision by the facility staff from the nurses' station or similar location.

This deficient practice was confirmed by facility Staff H at the time of discovery.

Based on observation and interview, the facility failed to provide corridor doors meeting the requirements of NFPA 101 (2012 edition), 19.3.6.3, 19.3.6.3.1, 19.3.6.3.2 and 19.3.6.3.5. These deficient practices would affect 3 of the 12 patients, and an undetermined number of staff and visitors.

Findings include:

1. On 4/9/18 at 12:14 pm, observation on the ground floor in the kitchen at the double doors leading to the corridor revealed the doors did not positively self-latch.
2. On 4/9/18 at 2:12 pm, observation on the 2nd floor in all patient rooms in the 2G and 2F smoke compartments revealed double doors on the corridor with up to a 1/4 gap between the door leaves. The doors were not outfitted with astragals and did not resist the passage of smoke. Facility Staff G confirmed the corridors were smoke detected, but the resident rooms had no smoke detection.

These deficient practices were confirmed by facility Staff G & H at the time of discovery.

Based on observation and interview, the facility failed to provide properly fire-stopped smoke barriers in accordance with NFPA 101 (2012 edition), 19.3.7.3 and 8.5. This deficient practice could affect 3 of the 14 patients, as well as an undetermined number of staff and visitors.

Findings include:

On 4/9/18 at 1:04 pm, observation on the 3rd floor of the smoke barrier wall in the corridor above the drop ceiling at the smoke barrier doors between the 3A and 3B smoke compartments revealed a 1-hour assembly with gypsum drywall joints untaped and mudded, drywall fasteners unprotected; and numerous unprotected penetrations from sprinkler piping, electrical conduit, and cable bundles.

This deficient practice was confirmed by facility Staff G & H at the time of discovery.

Based on observation and interview, the facility failed to provide smoke barrier doors in accordance with NFPA 101 (2012 edition), 18.3.7.8(4) and 8.5.4. The building was constructed in 2003-2004 and required to meet Chapter 18 new requirements at the time of construction. This deficient practice could affect 3 of the 13 patients, as well as an undetermined number of staff and visitors.

Findings include:

On 4/9/18 at 1:05 pm, observation of the pair of cross-corridor smoke barrier doors between the 3A and 3B smoke compartments revealed no astragals, rabbets or bevels and up to a 1/4 inch gap by 83 inches at the meeting edges of the pair of cross-corridor smoke barrier doors.

This deficient practice was confirmed by facility Staff G & H at the time of discovery.

Based on observation and interview, the facility failed to maintain the electrical system in accordance with the requirements of NFPA 101 (2012 edition), Chapter 39; as well as NFPA 70 (2011 edition). This deficient practice could affect 2 of the patients as well as an undetermined number of staff and visitors.

Findings include:

On 4/9/18 at 2:55 pm, observation revealed a freezer plugged into a power strip.

This deficient practice was confirmed by facility Staff G & H at the time of discovery.

Based on observation and interview, the facility failed to provide protection for trash collection receptacles exceeding 32 gallons in capacity in accordance with NFPA 101 (2012 edition), 19.7.5.7. This deficient practice could affect 3 of the 13 patients and an undetermined number of staff and visitors.

Findings include:

On 4/9/18 at 1:15 pm, observation on the 3rd floor in the elevator lobby of the 3B smoke compartment revealed a mobile 4 foot by 2 foot by 5 foot high soiled linen storage container with soiled linen unattended and in storage. Staff G stated the storage was temporary storage due to construction activities.

The deficient practice was confirmed by facility Staff G & H at the time of discovery.