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Based on observations and staff interview, the facility failed to maintain all 2 hour rated walls with doors at least 1-1/2 hour fire rated in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.1.3.5 and 8.2.1.3. The facility has a capacity of 25 with a census of 18 residents.

Findings include:

Observations and staff interview on 5/7/18, between 11:00 a.m. to 5:00 p.m., revealed the following deficiencies:

1. There was a penetration, (approximately 1/2 inch), around a black cable extending through the 2 hour wall separating the Emergency Department from the Ambulance Garage.
2. There was a penetration, (approximately 1 inch), around a gray cable extending through the 2 hour wall separating the Emergency Department from the Ambulance Garage.
3. There was a penetration, (approximately 1 inch), around 2 conduit extending through the 2 hour wall to the Lobby by the Giftshop.
4. There was a penetration, (approximately 3 inches), around a gray wire extending through the 2 hour wall in the old OB Hallway with doors labeled FD2-37.
5. There were 2 penetrations, ( both approximately 1/4 inch), around 2 open pipes extending through the 2 hour wall in the old OB Hallway with doors labeled FD2-37.
6. There were 2 open pipes, (approximately 3 inches), extending through the 2 hour wall in the old OB Hallway with doors labeled FD2-37.
7. There was an open pipe, (approximately 5 inches), extending through the Clinic 2 hour wall by Room 213.
8. There were 8 holes, (all approximately 1/4 inch), in the 2 hour wall between the North end of the Medical Surgical floor and the Clinic.

Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain all stairwells with a fire resistance rating of a minimum of one hour in accordance with National Fire Protection Association, 2012 Life Safety Code, 19.3.1.1 through 19.3.1.6. The facility has a capacity of 25 with a census of 18 patients.

Findings include:

Observation and staff interview on 5/7/18 at 1:10 p.m., revealed a penetration, (approximately 1/4 inch), around a sprinkler pipe extending through the wall of the 3rd Floor Northwest Stairwell. Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. The facility has a capacity of 25 with a census of 18 patients.

Findings include:

Observation and staff interview on 5/7/18 at 3:22 p.m., revealed a fire alarm audio/visual notification device was not installed in the enclosed courtyard near the Cafeteria. Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. The deficient practice affects all occupants of the building.

Findings include:

Observation and staff interview on 5/9/18 at 2:30 p.m., revealed the following deficiencies:

1. The circuit breaker supplying power to the fire alarm system was not mechanically protected.
2. The location of the power supply for the fire alarm system was not labeled at the main fire alarm control panel.
3. There was a smoke detector installed near an air supply or return ventilation duct in the Lobby by the entrance to the Rehab Center.
4. There was a smoke detector installed near an air supply or return ventilation duct in the Rehab Center near Treatment Room
5. There was a smoke detector installed near an air supply or return ventilation duct in the southeast corner of the Lobby.

Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to and maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. The fire alarm system shall give an audible signal upon loss of a phone line at a panel monitored 24 hours. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 18 patients.

Findings include:

Observation and staff interview on 5/7/18 at 4:17 p.m., revealed the fire alarm system did not send an audible signal upon loss of a phone line to the fire annunciator panel located at the Emergency Department Entrance. The system indicated the following: "remote sounders inhibited." Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to inspect and maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. A fire alarm system shall be inspected twice a year, at an interval of 6 months. The deficient practice affects all occupants of the building.

Findings include:

Record review and staff interview on 5/9/18 at 11:51 a.m., revealed the fire alarm system for the Knoxville Clinic has not been inspected twice a year, at an interval of 6 months as required. The fire alarm system was last inspected on 2/27/17 and 2/27/18. Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to inspect and maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. A fire alarm system shall be inspected twice a year, at an interval of 6 months. The deficient practice affects all occupants of the building.

Findings include:

Record review and staff interview on 5/9/18 at 12:05 p.m., revealed no available documentation of semi-annual inspections for the Orthopedic Center fire alarm system.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the fire alarm system is out of service for more than four hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.6.1.6. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 18 patients.

Findings include:

Record review and staff interview on 5/9/18 at 10:52 a.m., revealed the outage policy for the fire alarm system did not indicate notification of authorities having jurisdiction at the beginning and end of the impairment. Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, this facility is not maintaining the sprinkler system in accordance with National Fire Protection Association, NFPA 25, 2011 edition and National Fire Protection Association, NFPA 13, 2010 edition. The deficient practice affects all occupants of the building.

Findings include:

Record review and staff interview on 5/9/18 at 11:55 a.m., revealed no available documentation of quarterly sprinkler system inspections for the Knoxville Clinic. The system was last inspected on 4/24/17. Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, this facility is not maintaining the sprinkler system in accordance with National Fire Protection Association, NFPA 25, 2011 edition and National Fire Protection Association, NFPA 13, 2010 edition. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 18 residents.

Findings include:

Record review and staff interview on 5/9/18 at 10:12 a.m., revealed the last available documentation of a 5 year sprinkler system inspection for the following areas was last completed on 4/17/12 and 4/18/12: South Riser. Medical Office Building. Boiler Room Risers. Maintenance Staff verified record review during the survey process.

Based on record review, observations and staff interview, this facility is not maintaining the sprinkler system in accordance with National Fire Protection Association, NFPA 25, 2011 edition and National Fire Protection Association, NFPA 13, 2010 edition. The deficient practice affects all occupants of the building.

Findings include:

Record review and staff interview on 5/9/18 at 12:05 p.m., revealed no available documentation of quarterly testing of the sprinkler system for the Orthopedic Center. Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the sprinkler system is out of service for more than 10 hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.7.6. and NFPA 25, 15.5.2, 2011 Edition. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 18 patients.

Findings include:

Record review and staff interview on 5/9/18 at 10:52 a.m., revealed the following deficiencies:

1. The policy did not state that authorities having jurisdiction will be contacted at the beginning and end of the impairment.
2. The policy did not address the following conditions: System leakage. Ruptured piping. Interruption of water supply. Equipment failure.

Maintenance Staff verified record review during the survey process.

Based on observation and staff interview, the facility failed to provide and maintain smoke barrier doors with a 20 minute fire rating in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.7.6. The facility has a capacity of 25 with a census of 18 residents

Findings include:

Observation and staff interview on 5/7/18 at 1:13 p.m., revealed a large gap between the smoke barrier doors in the 2008 Edition by Room 11. The gap was large enough to see through the doors to the corridor on the other side. Maintenance Staff verified observations during the survey process.

Based on observations and staff interview, the facility failed to maintain the building's electrical system in accordance with National Fire Protection Association, NFPA 70, 2010 Edition. The facility has a capacity of 25 with a census of 18 patients.

Findings include:

Observations and staff interview on 5/9/18between 1:25 p.m. and 1:49 p.m., revealed the following deficiencies:

1. Circuit breaker #9, located in Electrical Panel RIN-201B was in the tripped position.
2. Not all circuit breakers were identified in the following electrical panels: LIN-101. LIC-101. LIS-101.

Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to provide emergency plans and procedures as required by National Fire Protection Association, NFPA 101, 2012 Edition, 19.7.2.2. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 18 patients.

Findings include:

Record review and staff interview on 5/9/18 at 11:05 a.m., revealed the facility's fire emergency plan and procedure did not contain activation of the Kitchen Hood and Duct System and use of K rated extinguishers. Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to maintain and test each generator set in accordance with National Fire Protection Association, NFPA 110, 2010 Edition. A monthly test under load shall be conducted. The deficient practice affects all occupants of the facility. The facility has a capacity of 25 with a census of 18 patients.

Findings include:

Record review on 5/9/18 at 11:22 a.m., revealed the following deficiencies:

1. Available documentation of monthly generator tests did not contain the start and stop times to verify the system was operated at a minimum of 30 minutes under load.
2. Available documentation of monthly generator tests under load did not contain information on operation of the transfer switch prior to the month of April, 2018.

Maintenance Staff verified record review during the survey process.

Based on observation and staff interview, the facility did not store compressed gas cylinders in accordance with National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 11.6.2.3, by ensuring tanks were adequately secured to prevent them from accidental damage or dislocation. The facility has a capacity of 25 with a census of 18 patients.

Findings include:

Observation and staff interview on 5/7/18 at 3:06 p.m., revealed a large carbon dioxide cylinder that was not properly secured in the Carbon Dioxide Supply Room. Maintenance Staff verified observations during the survey process.