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Based on observation and interview, the provider failed to maintain the fire-resistive design of the building at one random ceiling location (room 149, the air handler room). Findings include:

1. Observation at 11:55 a.m. on 7/24/19 revealed the ceiling was missing for room 149, air handler room. The room had a fire sprinkler situated just below where the ceiling had apparently been in the past. The open space above the sprinkler continued to a roof fan unit and would prevent the sprinkler from operating correctly. Interview with the maintenance supervisor at the time of the observation revealed the ceiling had been removed sometime in the past to allow equipment maintenance of the air handler.

The deficiency could affect 100% of the occupants of the smoke compartment.

Based on observation, testing, and interview, the provider failed to provide egress doors as required at one of five locations (shared corridor with building one). Findings include:

1. Observation at 3:15 p.m. on 7/24/19 revealed the cross-corridor exit doors for building two at the two-hour, fire-rated wall separating building two from building one were equipped with magnetic door locks. The door on the right side going from building two to building one did not have a motion sensor and was identified as being a delayed egress type magnet lock. Testing of the door by applying pressure to the panic bar revealed the force exerted would not initiate the release process. Further testing by a staff person did initiate the release sequence after exerting an inordinate amount of force. The door also did not have any signs as required for delayed egress magnetically locked doors. Interview with the maintenance supervisor at the time of the observation revealed he was unaware the magnet lock was not in compliance.

Failure to provide egress doors as required increases the risk of death or injury due to fire.

The deficiency affected one of five exit doors.

Ref: 2012 NFPA 101 Section 19.2.2.2.4(3), 7.2.1.6.2(3)(a)

Based on observation and interview, the provider failed to maintain one of two hazardous areas (boiler room) as required (door undercut too high and unsealed penetrations). Findings include:

1. Observation at 2:00 p.m. on 7/24/19 revealed the fire-rated door for the boiler room had an undercut of 1.5 inches. The maximum undercut for a fire-rated door was 3/4 inches.

2. Observation at 2:15 p.m. on 7/24/19 revealed several unsealed penetration openings of the boiler room walls by water piping and electrical conduits. The penetration openings must be sealed with an approved fire-stop material such as intumescing fire caulk.

3. Interview with the maintenance supervisor at the times of the observations confirmed those findings.

The deficiency affected two of numerous requirements for hazardous rooms.

Based on observation and interview, the provider failed to replace one random fire extinguisher inside the mechanical room by the nurses station (the pressure gauge was in the red). Findings include:

1. Observation at 3:10 p.m. on 7/24/19 revealed an ABC fire extinguisher inside the mechanical room by the nurses station. The indicating arrow for the pressure gauge was outside the green operating limit and was in the red (defective). Interview with the maintenance supervisor at the time of the observation confirmed that finding. He stated the fire extinguishers had all been through their annual inspections four months prior to the survey.

The deficiency affected one of numerous requirements for installing and maintaining fire extinguishers.

Based on observation, record review, and interview, the provider failed to adequately maintain fire-rated door characteristics at one of three exit doors (connecting corridor for building one to building two). Findings include:

1. Observation at 3:15 p.m. on 7/24/19 revealed building one shared an egress corridor with building two where the two buildings connected adjacent to the chapel in building one. Record review revealed the building connection was a two-hour, fire-rated wall with ninety-minute, fire-rated alternate swing cross-corridor doors. The doors did not have two points of latching required for wood ninety-minute, fire-rated doors. The doors were equipped with panic hardware that had striker rods at the top of the doors. The door frame did not have any striker plates to receive the striker rods. Further observation revealed the frame had holes where the striker plate location would have been. Further observation revealed the second point of latching for the wood doors was a thermal pin located approximately twelve inches above the floor. The doors did not line up and would affect the ability of the thermal pin to adequately latch into the second door leaf.

Interview with the maintenance supervisor at the time of the observation confirmed that finding. He stated he was unaware the doors in question were required to latch.

The deficiency had the potential to affect 100% of the building occupants of both building one and building two.

Based on observation and interview, the provider failed to maintain requirements for oxygen storage (storage of combustible items within five feet of oxygen cylinders) for the oxygen cylinder storage room. Findings include:

1. Observation at 11:45 a.m. on 7/24/19 revealed one wall of the mechanical room by the nurses station in the patient wing with three shelves mounted above the oxygen cylinders kept in the room. The shelves had combustible items (Christmas decorations, plastic totes, furnace air filters, and scrub pads) stored on them. Those items were within five feet of the oxygen E cylinders in the oxygen cylinder storage room.

Interview with the maintenance supervisor at the time of the above observations confirmed those findings.

The finding violated one of numerous requirements for the storage of oxygen.