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Based on observation and staff interview the facility failed to maintain the proper 2 hour fire resistive ratings for occupancies as described in the Life Safety Code (NFPA 101) 2012 edition section 19.1.3.3. This deficient practice could allow for the transfer of smoke or fire from another occupancy and affect an undetermined amount of patients.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 09/13/2018 Observations revealed penetrations in the following 2 hour fire barriers without the proper fire stopping.
1. The Ambulance garage has four, 4 inch pipes, in the ends of each and two 4 inch pipes around the annular space, and a 3 x 5 hole in the block.
2. The outpatient therapy entrance above the ceiling has a 2 1/2 inch conduit not properly fire stopped in the end of it.

Observations revealed the door on the south wall of the blood draw room, which is part of the 2 hour fire barrier did not have a 90 minute door.

This deficient condition was confirmed by the Maintenance Director.

Based on observation and staff interview the facility failed to maintain two hazardous rooms in accordance with the 2012 Life Safety Code (NFPA 101) section 19.3.2.1.3. This deficient condition could allow smoke or fire to enter adjacent rooms and the corridor making it untenable and affect the quick and efficient exiting for an undetermined amount of patients.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 09/13/2018 Observations revealed the following locations have penetrations from the installation of new chiller pipes and the area around the pipes were not properly fire stopped.
1. The lower level record storage room.
2. The lower level boiler room.

This deficient condition was confirmed by the Maintenance Director.

Based on observations and staff interview the facility failed to install the smoke detection in accordance with NFPA 101 Life Safety Code (2012) section 19.3.4.1, 9.6.1.3 and NFPA 72 National Fire Alarm Code (2010) section 17.7.4.1. This deficient practice could affect the ability of the alarm system to sound in a timely manner during a fire event which could affect all patients.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 09/13/2018 observations revealed the following locations have smoke detectors installed within 36 inches of an HVAC diffuser.
1. The 2nd floor Nurse coordinators office
2. The men's locker room in the surgery dept.
3. Outpatient surgery, rooms 1,2,3,and 4
4. The bone density room
5. The lower level on call room
6. The hall in Quality Customer Svc dept.

This deficient condition was confirmed by the Maintenance Director.

Based on observation and staff interview the facility failed to install sprinkler heads in accordance with the 2012 edition of the Life Safety Code (NFPA 101) sections 19.3.5.1, 9.7.1.1 and the 2010 edition of NFPA 13, The Standard for the Installation of Sprinkler Systems. This deficient practice could cause a delay in extinguishing a fire affecting the safety of an undetermined amount of patients.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 09/13/2018 observations revealed the sprinkler heads in the new chiller room were not changed to upright type heads from the existing pendant style after the ceiling tiles were removed.

This deficient condition was confirmed by the Maintenance Director.

Based on observation and staff interview, the facility failed to maintain the sprinkler system in accordance with the 2012 Life Safety Code (NFPA 101) and NFPA 25 section 5.2.1.1.2. The standard for testing and maintenance of sprinkler systems. This deficient condition could cause the sprinkler system not to function properly and allow for the spread of fire. This could affect an undetermined amount of patients.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 09/13/2018 observations revealed the fluid in the sprinkler head in the kitchen cooler has changed from red to orange.

This deficient condition was confirmed by the Maintenance Director.

Based on observation and staff interview the facility failed to maintain one of five smoke barriers as required by the 2012 Life Safety Code (NFPA 101) section 19.3.7.3, 8.8.7.1 (1). This deficient practice could allow smoke to transfer from one smoke compartment to another affecting the exiting of 10 of the 25 patients.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 09/13/2018 observations revealed the annular space around two 3/4 inch pipe penetrations above the ceiling at the corridor door were not properly fire stopped in the smoke barrier on the 2nd floor across from the nurses station.

This deficient condition was confirmed by the Maintenance Director.

Based on record review and staff interview the facility failed to conduct fire drills under varied conditions on each shift as required by the Life Safety Code (NFPA 101) 2012 edition, section 19.7.1.4 to 19.7.1.7. This deficient practice could reduce the ability of staff to conduct a safe and timely response to a fire emergency, which would affect all 25 patients.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 09/13/2018 documentation review revealed the fire drills on the 2nd shift during the last 4 quarters were not conducted under varied conditions.

This deficient condition was confirmed by the Maintenance Director.

Based on documentation review and staff interview, the facility failed to inspect the building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. The deficient practice could affect all patients.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 09/13/2018 documentation review revealed there was no record of a risk assessment being completed based on NFPA 99.

This deficient condition was confirmed by the Maintenance Director.

Based on record review and staff interview the facility failed to provide inspection documentation in accordance with the 2012 edition of the Life Safety Code (NFPA 101) section 9.1.3.1 and the 2010 edition of NFPA 110 the Standard for Emergency and Standby Power Systems. This deficient practice could affect the safety of all of the 25 patients.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 09/13/2018 record review revealed there was no documentation of a weekly generator inspection for the first week of September in 2018.

This deficient condition was confirmed by the Maintenance Director.

Based on observation and staff interview the facility failed to ensure multiple outlet adapters are in accordance with the 2012 edition of NFPA 99 section 10.2..4.2.1 and the use of power strips comply with 10.2.3.6. This deficient practice could affect and an undetermined amount of patients.

Findings include:

On the facility tour between 8:00 am to 3:00 pm on 09/13/2018 observations revealed 2 power strips daisy changed with a microwave and refrigerator plugged into them on the lower level in the Diabetes Nutrition Office.

This deficient condition was confirmed by the Maintenance Director.