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Based on observation and interview, the facility failed to maintain the two-hour rated separation in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.1.3, 19.1.3.3, 8.3, 8.3.1, 8.3.1.2, 8.3.3, 8.3.3.1 and 8.3.5. This deficient practice has the potential to affect an undetermined number of staff and visitors.

Findings include:

1. On 09/21/2022 at 8:59 am observation at the 2-hour rated occupancy separation wall between the hospital and the previous nursing home revealed that a 2" conduit was not fire stopped according to an approved method.

2. On 09/21/2022 at 9:00 am observation of the 90-minute double door in the 2-hour rated occupancy separation wall between the hospital and the previous nursing home revealed that the door did not positively latch, 3 out of 3 times, upon closing with the door closer.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff S and Staff T.

Based on observation and interview, the facility failed to protect a hazardous area in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.2.1.3, 19.3.2.1.5. This deficient practice could affect an undetermined number of staff and visitors.

Findings include:

1. On 09/20/2022 at 1:59 pm observation in the sterile corridor at the OR suite, the storage room door was not equipped with a self-closer or automatic closing hardware. The room was larger than 50 sf.

2. On 09/20/2022 at 2:36 pm observation in the emergency room area, the storage room door was not equipped with a self-closer or automatic closing hardware. The room was larger than 50 sf.

3. On 09/20/2022 at 3:12 pm observation in the corridor near the training room, two former offices were being used for storage. The rooms contained multiple cardboard boxes of combustible items in quantities large enough to classify the room as hazardous. The doors were not equipped with a self-closer or automatic closing hardware. The rooms were larger than 50 sf.

4. On 09/21/2022 at 7:58 am, observation in the kitchen dry storage room revealed that the fire rated door of the dry storage was not equipped with a self-closer or automatic closing hardware.

These deficiencies were confirmed at the time of discovery by a concurrent interview with Staff S and Staff T.

Based on observation and interview, the facility did not maintain smoke barriers in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.7, 19.3.7.1, 19.3.7.3, 8.5, 8.5.2 and 8.5.6. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

1. On 09/21/2022 at 8:24 am observation above the cross-corridor double egress doors in the smoke barrier wall by soiled utility in the main corridor revealed a 1" diameter hole through the wall that was not sealed with an approved listed/tested fire and smoke proofing system.

2. On 09/21/2022 at 8:31 am observation above the cross-corridor double egress doors in the smoke barrier wall by the emergency department revealed a 4" x 4" metal box installed through the wall beside a removed smoke damper. The box was not sealed by an approved listed/tested fire and smoke proofing system.

3. On 09/21/2022 at 9:03 am observation above the cross-corridor double egress doors in the smoke barrier wall by the locker rooms in the cross corridor revealed a 2" diameter hole through the wall that was not sealed with an approved listed/tested fire and smoke proofing system.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff S and Staff T.

Based on record review and interview, the facility did not perform testing of the emergency generator in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.5.1 and 9.1.3; and NFPA 110 (2010 edition) Sections 8.3.7, 8.3.8, 8.4.1, 8.4.2, & 8.4.6. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

On 09/20/2022 at 10:38 am, review of the monthly generator documentation revealed that neither specific gravity testing nor conductance testing of the generator batteries was recorded for 12 of the last 12 months.

This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff A and Staff B.

Based on observation and interview, the facility failed to maintain a clear working space in front of one electrical panel in accordance with NFPA 101 (2012 edition) Section 9.1.2; NFPA 70 (2011 edition) Sections 110.26 & 110.34 (A). The deficient practice could an undetermined number of staff and visitors

Findings include:

1. On 09/20/2022 at 1:56 pm, observation in the sterile corridor revealed that access to the electrical panel was less than the minimum required 3'-0" clearance. A rolling cart and medical equipment was stored in front of the electrical equipment.

2. On 09/20/2022 at 2:18 pm, observation in the ambulance bay revealed that access to an electrical panel was less than the minimum required 3'-0" clearance. A sandwich board for Covid Testing was leaned against the electrical panel.

3. On 09/20/2022 at 2:39 pm, observation in the exam corridor revealed that access to the electrical panel was less than the minimum required 3'-0" clearance. A rolling scale was stored in front of the electrical panel.

These deficient practices were confirmed at the time of discovery by concurrent interviews with Staff S and Staff T.