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Based on observation and interviews, the facility failed to properly maintain exit egress as per NFPA 101 section 19.2.2.2.6. This deficiency practice affected the entire facility on the day of survey.

Findings include:

On August 14, 2018, at 2:00 PM, observation and testing of the fire alarm revealed the mean of egress from the 2nd Geropsych Area was blocked by the magnetic lock doors. The magnetic locks on the doors of the 2nd Geropsych Area re-engaged and locked when the fire alarm system was silenced. The magnetic locks shall remain unlocked until the fire alarm system is reset to normal status.

Based on observations, the facility failed to properly protect hazardous areas NFPA 101 section 19.3.2.1. This deficiency practice affected the entire facility on the day of survey.

Findings include:

Observations during the building inspection on August 14, 2018 at 10:40 AM revealed the ceilings in the PACS Room and Medical Records Room contain holes. These ceilings were unable to resist the passage of smoke throughout the facility. The PACS Room contained a 4' x 6' hole and the Medical Records Room contained a 2' x 8' hole.

Based on observations, the facility failed to have a properly installed fire alarm system as required by NFPA 72 section 2-8.1. This deficiency practice affected the entire facility on the day of survey.

Findings Include:

On August 14, 2018 at 12:30 PM, observation revealed the fire alarm dialer was not located in a continuous supervised/occupied area of the facility. The fire alarm dialer also was not protected by a hard wired smoke detector.

Based on record review, the facility failed to provide a properly maintained fire alarm system as required by NFPA 72 section 14.4.5.3.2. This deficiency practice affected the entire facility on the day of survey.


Findings Include:

On August 14, 2018 at 1:45 PM, record review revealed the facility had no documentation of a sensitivity inspection of the fire alarm system. Interview with the Maintenance Supervisor revealed the fire alarm company informed facility sensitivity test was not required for the fire alarm system.

Based on observation, the facility failed to properly protect corridor openings as directed by NFPA 101 section 19.3.6.4.1. This deficiency practice affected the entire facility on the day of survey.

Findings Include:

On August 14, 2018 at 11:00 AM, observation revealed the air transfer grilles in the following corridor doors of the Radiology Room, Mammography Room, Bone Density Room, and File Room. These corridor doors were unable to resist the passage of smoke throughout the facility.

Based on record review and interviews, the facility failed to properly perform fire drills as per NFPA 101 section 19 .7.1.7. This deficiency practice affected the entire facility on the day of survey.

Findings include:

On August 14, 2018 at 1:30 PM, record review and interviews revealed the facility was not activating the fire alarm system while conducting fire drills during the 3rd shift in the 1st and 2nd quarters of 2018. All fire drills conducting between the hours 6 AM to 9 PM must have an audible signal. Interview with the Safety Personnel revealed the facility staff was unaware that fire drills must be audible from 6AM thru 9PM.