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Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th, 2014, and it was observed that the facility failed to provide and maintain the one-half hour fire-rating and smoke tightness of the smoke barrier walls in accordance to NFPA 101 Section 19.3.7.3 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 8 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

A verification visit was conducted on May 12, 2014 of this hospital and the following findings remain from the original survey.

Findings include:

1. On March 25th, 2014 at 11:13 am it was observed that the south wall of the Locker room for PT did not have drywall installed above the ceiling and taped and plastered to a one-half hour rating for this smoke compartment wall.

2. On March 25th, 2014 at 11:15 am it was observed that the north and east walls of the Hydrotherapy room were not completely covered with gypsum wall board. Mineral wool was not installed at the top of the wall and covered with fire caulk. Additionally, 5 penetrations in these walls were not fire caulked to a one-half hour rating for these smoke compartment walls.

These deficient practices were confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th, 2014 and it was observed that the facility failed to provide and maintain the one-hour rated enclosures with 45-minute rated doors into hazardous areas per NFPA 101 [2000 Ed] Section 19.3.2.1 as evidenced by the following item(s). This deficient practice could affect all of the patients in the smoke compartment where these rooms were located, as well as an undetermined number of staff and visitors. This facility contains 8 smoke compartments.

A verification visit was conducted on May 12, 2014 of this hospital and the following findings remain from the original survey.

Findings include:

1. On March 25th, 2014 at 10:20 am it was observed that the north wall of Central Supply was not construction to a one-hour fire-rating. The wall was constructed of concrete block that did not extend up to the roof deck along 12 lineal feet of this wall. All penetrations were not fire caulked as required.

2. On March 26th, 2014 at 8:30 am it was observed that Lab Storage did not have drywall installed above the ceiling to the deck along most of the perimeter walls of this space. This is a storage room with combustible storage greater than 100 square feet and should be constructed to a one-hour fire barrier rating.

3. On March 26th, 2014 at 8:48 am it was observed that Emergency Power electrical room which was constructed to a one-hour fire rating had a 20-minute rated door installed that led to the corridor. This door is required to be at least a 45-minute rated door from this room.

4. On March 26th, 2014 at 10:09 am it was observed that Soiled Utility near patient room #222 was not taped and mudded to a one-hour fire barrier rating along most of the perimeter of this space. It was observed that the screw heads were not mudded. These conditions occurred on both side of this one-hour enclosure.

5. On March 26th, 2014 at 10:24 am it was observed that Pharmacy Storage was not taped and mudded to a one-hour fire barrier rating along the entire perimeter of this space. This condition occurred on both side of this required one-hour enclosure. The use of this space changed from a non-rated room as originally constructed to this storage room greater than 100 square feet in area which requires a one-hour fire barrier enclosure.

These deficient practices were confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor, between March 24th and March 26th, 2014, it was observed that the facility failed to provide and maintain a sprinkler system that was installed in accordance to the Life Safety Code [2000 Ed] Sections 19.3.5.1 and 9.7.1.1 and NFPA 13 [1999 Ed] Section 5.1.1. The deficient practice could affect all the patients, staff and an undeterminable number of visitors within the 8 smoke compartments of this building.

A verification visit was conducted on May 12, 2014 of this hospital and the following findings remain from the original survey.

Findings include:

1. On March 25th, 2014 at 9:22 am, it was observed that wood framing from an old skylight and plywood decking were found within the ceiling space above the Corridor leading to the Car Port. This combustible material within a concealed space triggers sprinkler protection which was not present and hence does not meet NFPA 13 (1999 Ed) Section 5-13.1.1.

2. On March 25th, 2014 at 10:38 am, it was observed that plywood decking was found covering a hole in the steel decking within the ceiling space above the Corridor leading to the Loading Dock. This combustible material within a concealed space triggers sprinkler protection which was not present and hence does not meet NFPA 13 (1999 Ed) Section 5-13.1.1.

3. On March 25th, 2014 at 10:40 am, it was observed that wood blocking was found within the ceiling space above the Biohazard room near the Car Port. This combustible material within a concealed space triggers sprinkler protection which was not present and hence does not meet NFPA 13 (1999 Ed) Section 5-13.1.1.

4. On March 25th, 2014 at 3:27 pm, it was observed that 5 pendent sprinkler heads were found within the Radiology workstation that were all spaced less than 6'-0" apart. This spacing between the 5 different pendent heads did not meet NFPA 13 (1999 Ed) Section 5-6.3.4.

5. On March 26th, 2014 at 10:24 am, it was observed that pendent sprinkler heads installed within most of the Patient Room Closets did not provide the 18" clear space below the sprinkler deflector. This obstruction to the sprinkler discharge did not meet NFPA 13 (1999 Ed) Section 5-6.5.3.

6. On March 26th, 2014 at 10:39 am, it was observed that no sprinkler head was installed within Electrical closet near ICU. This omission of a sprinkler head within this space did not meet NFPA 13 (1999 Ed) Section 5-13.11.

These deficient practices were confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.