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Based on observation and interview, the facility failed to maintain the two-hour rated, occupancy separation between the hospital and the Heritage Building in a accordance with the requirements of NFPA 101 (2012 edition), sections 19.1.3.5 and 8.2.1.3. This deficient practice could affect 11 of 11 patients, plus an undetermined number of staff and visitors.

Findings include:

On 01/08/2018 at 12:49 pm, observation revealed the double door, closest to the kitchen, in the two-hour, fire-rated, wall between the hospital and Heritage Building did not fully close and latch.

This deficiency was confirmed at the time of discovery by a concurrent interview with Staff C.

Based on observation and interview, the facility failed to maintain the two-hour rated, occupancy separation between the rehab wing of the hospital and Essentia Clinic building in accordance with the requirements of NFPA 101 (2012 edition), sections 19.1.3.5 and 8.2.1.3. This deficient practice could affect 11 of 11 patients, plus an undetermined number of staff and visitors.

Findings include:

On 01/09/2018 at 10:36 am, observation revealed the double doors in the two-hour, fire-rated, wall between the rehab wing of the hospital and Essentia Clinic building did not fully close and latch because the door coordinator held the door open.

This deficiency was confirmed at the time of discovery by a concurrent interview with Staff C.

Based on observation, record review and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 9.7.5 and NFPA 25 - 2011 edition, Sections 5.1.1.2 & 5.2.1. These deficient practices could affect 11 of 11 residents, plus an undetermined number of staff and visitors.

Findings include:
1. On 1/08/18 at 10:00 am, it was noted during a review of the most recent annual fire sprinkler system inspection/test reports that there was no record of a five year inspection and testing of the sprinkler system.
2. On 01/08/18 at 12:36 pm, observation revealed that sprinklers in the kitchen were not kept free of lint and other foreign material.

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

Based on observation, record review and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 9.7.5 and NFPA 25 - 2011 edition, Sections 5.1.1.2 & 5.2.1. These deficient practices could affect 11 of the 11 patients, plus an undetermined number of staff and visitors.

Findings include:
1. On 1/08/18 at 10:00 am, it was noted during a review of the most recent annual fire sprinkler system inspection/test reports that there was no record of a five year inspection and testing of the sprinkler system.
2. On 01/08/18 at 13:30 pm, observation revealed that sprinklers in the volunteer locker room were not kept free of lint and other foreign material.
3. On 01/09/18 at 9:33 am, observation revealed that sprinklers in the clean central processing room were not kept free of lint and other foreign material.
4. On 01/09/18 at 10:07 am, observation revealed that sprinklers in the Woods Wing nourishment room were not kept free of lint and other foreign material.
5. On 01/09/18 at 10:18 am, observation revealed that sprinklers in the OB nurses station were not kept free of lint and other foreign material.

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

Based on observation and staff interview, the facility failed to maintain corridor doors in accordance with NFPA 101(2012 ed.) 19.3.6.3. These deficient practices could affect 3 of 11 patients, plus an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 01/08/18 at 13:15 pm, observation revealed that the corridor door to the ER break room was held open with a wooden door wedge.
2. On 01/08/18 at 13:45 pm, observation revealed that the corridor door to the lab storage/coat room would not close and latch, because the latching mechanism was disabled.
3. On 01/08/18 at 13:55 pm, observation revealed that the corridor door to the endoscopy cleaning room would not fully close and latch.

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

Based on observation and interview, the facility failed to maintain smoke barrier walls 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. These deficient practices could affect an undetermined number in patients, out patients, staff and visitors.

Findings include:
1. On 01/09/18 at 11:00 am, observation revealed above the ceiling at the employee hallway smoke barrier wall, above the door near the lab, that there were 4 conduit penetrations with communication wires that were not properly fire stopped.
2. On 01/09/18 at 11:05 am, observation revealed above the ceiling in the main corridor, in the lab smoke compartment wall, that there were 3 - 1 ½ inch conduit penetrations with communication wires that were not properly fire stopped.
3. On 01/09/18 at 11:11 am, observation revealed above the ceiling, in the main corridor adjacent to the gift shop, above the door, that there was a 4" conduit not sealed and plugged with communication wires and 2 holes in the smoke walls that were not properly fire stopped.

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