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Based on observation it was determined the facility failed to fill penetrations in two of two smoke barriers. Observation of the two hour and four hour smoke barrier doors revealed, the smoke barrier door seals were torn and the rated doors were not latching when tested to close and latch tightly.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 "Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or /ceiling assembly, constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling, of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke...."

Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors, or of construction that resists fire for 20 minutes.

Findings include:

On March 23, 2017 the surveyor, accompanied by the Director of Plant Operations observed unsealed penetrations, holes or conduit penetrations which went through both sides of the smoke barriers located by rooms 115 and Administration offices.

The following smoke barrier doors had either torn smoke barrier seals, or the doors did not latch and close tightly when tested.

- The two hour and four hour rated smoke barrier doors on the first floor, and the smoke barrier doors adjacent to room 115.

During the exit conference on March 23, 2017 the above findings were again acknowledged by the Chief Executive Office, Patient Safety Officer and the Director of Plant Operations.

Failing to the penetrations, holes in the smoke barriers, replace torn smoke barrier seals and adjust or repair smoke barrier doors to close and latch will allow smoke and heat to penetrate other wings or possibly the whole facility, which could cause harm to the patients in time of a fire.

Based on observation, it was determined the facility failed to identify one of one panel board circuits in the second floor mechanical room electrical panel marked electrical panel 2E.

NFPA 101 Life Safety Code, 2012 , Chapter 19, Section 19.5.1."Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code "NEC, 2011, Article 408.4 (A) Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of panelboard, and located at each switch or a circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy...."

Findings include

On March 23, 2017, the surveyor, accompanied by the Director of Plant Operations observed the circuit breaker panel located in the second floor mechanical room marked electrical panel 2E did not have the circuit breakers identified.

During the exit conference on March 23, 2017 the above findings were again acknowledged by the Chief Executive Office, Patient Safety Officer and the Director of Plant Operations.

Failing to identify electrical circuits in an emergency could cause a fire or electrical shock, which may cause harm to patients.

Based on observation, it was determined, the facility failed to secure two medical gas E-type oxygen medical gas oxygen cylinders in a stand or cart, observed in the exterior oxygen storage area located by the liquid oxygen storage tank, and protect electrical devices, electrical receptacles, and wall outlets from damage.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99, 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart...."

NFPA 99 2012 Edition Standard for Health Care Facilities "Chapter 5 Section 5.1.3.3.2 Design and Construction. Section 5.1.3.3.2 (5) They shall be in compliant with NFPA 70 National Electrical Code, for ordinary locations. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements. Section 5-1.3.3.2 (5) Electrical devices should be physically protected, such as by use of protective barrier around the electrical devices, or by location of the electrical device such that it will avoid causing damage to the cylinders or containers. The device could be located at or above finished floor 1.5 m (5 ft) or other location that will not allow the possibility of the cylinders or containers to come into contact with the electrical device required by this section. Section 5.1.3.3.2 (10) They shall protect electrical devices from physical damage...."

Findings include:

On March 23, 2017, the surveyor accompanied by the Chief Executive Officer, Patient Safety Officer and the Director of Plant Operations, observed two unsecured medical gas oxygen cylinders E-type, located in the exterior oxygen storage area by the liquid oxygen storage tank, were not secured in a rack or stand.

In addition:

In the second floor oxygen storage room, the wall light receptacle outlet and the four way wall receptacle both were not five feet off the floor or protected from physical damage. The light switch and wall outlet receptacle were 3.5 feet off the floor.

During the exit conference on March 23, 2017 the above findings were again acknowledged by the Chief Executive Officer, Patient Safety Officer, and the Director of Plant Operations.

Failing to secure compressed medical gas cylinders could cause harm to the patients and staff.