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The facility has failed to ensure that the original fire rated construction of the building has been maintained. Failure to maintain fire separation construction could allow for smoke, heat, and fire to quickly spread through the building, and thus place patients, visitors, and staff at risk of fire.

The findings include, but are not limited to:

During the facility tour on July 25, 2017 between the hours of 10:45am and 2:30pm, I observed penetrations in fire barriers in the following locations:

1. Central supply has a hole in the ceiling.
2. Outdoor storage has unfinished fire rated wall.
3. Basement server room has 3 large holes in the wall.
4. Basement Central Supply Overflow has a square shaped penetration on the wall.

Interview with Mainteance Director revealed that maintenance staff was not aware of these breaches in fire walls.

These findings were observed and discussed with the Maintenance Director.

The facility has failed to ensure that the automatic sprinkler system is maintained in proper operating conditions at all times. Failure to maintain the sprinkler system may render it inoperable and thus place patience, visitors, and staff at risk of no sprinkler protection.

The findings include, but are not limited to:

During the facility tour on July 25, 2017 between the hours of 10:45 am and 2:30, I observed sprinkler head deficiencies in the following locations:

1. 1st floor Lab bathroom was observed to have escutcheon missing on the sprinkler head.
2. 2nd floor OR room behind autoclave has sprinkler escutcheon dropped and creating a penetration.
3. 2nd floor OR area by endoscope room has escutcheon has fallen and creating a penetration.
4. 1st floor IT closet has fire rated foam sprayed on sprinkler head.

Interview with Maintenance Director revealed that staff was not aware of these sprinkler head conditions.

These findings were observed and discussed with the Maintenance Director.

The facility failed to provide corridor doors that closed and latched properly as required. This provides conditions that make the doors incapable of resisting the passage of smoke. Failure on the part of the facility to provide doors that properly close and latch places patients, visitors, and staff at risk of the effects of smoke and heat.

The findings include, but are not limited to:

During the facility tour on July 25, 2017 between the hours of 10:45 am and 2:30, I observed fire rated doors to not close and latch when tested in the following locatiosn:

1. Fire doors on 2nd floor by reception did not close and latch when tested. This was fixed on site.
2. 1st foor bathroom corridor door across patient room A107 did not close and latch when tested.
3. Basement fire separation corridor doors to assisted living did not close and latch when tested. This was fixed on site.

Interview with Maintenance Director revealed that staff was not aware of these doors not working properly. Maintenance staff indicated that they are making preparations to be testing fire doors per new requirement.

These findings were observed and discussed with the Maintenance Director.

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The facility has failed to have the minimum amount of fire drills required. Failure to conduct regular fire drills could potentially place staff at risk of being unaware of duties to perform and evacuate the building in a timely manner. This could place patients, visitors, and staff of risk of injury or delays during an emergency evacuation.

The findings include, but are not limited to:

During document review on July 25, 2017 between the hours of 9:00am and 10:45am revealed that this facility has conducted one fire drill from January 2017 to June 2017.

Interview with the Maintenance Staff revealed that they have undergone many staff changes and are now back on track to performing fire drills as required. The staff also has scheduled Fire and Life Safety classes.

This finding was observed and discussed with the Maintenance Director.

The facility has failed to ensure that the premises is free of electrical hazards and is using power strips and adaptors in an approved manner. Failure to use power strips, extension cords, and electrical adaptors in an approved manner could allow for patients, visitors, and staff at risk of an electrical fire.

The findings include, but are not limited to:

During the facility tour on July 25, 2017 between the hours of 10:45 am and 2:30, I observed unapproved use of power strips and adaptors in the following locations:

1. Lab has a power strip plugged into an unapproved adaptor.
2. Radiology Office Manager office has an unapproved power strip. This was fixed on site.


Interview with Maintenance Director revealed that staff was not aware of these electrical hazards.

These findings were observed and discussed with the Maintenance Director.