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

Findings include:

On 07/10/18 at 1:48 pm, observation revealed the dietary office corridor door did not self-close and latch.

This condition was confirmed at the time of discovery by a concurrent interview with Staff Q, Staff R and Staff S.

Based on record review and staff interview, the facility did not ensure that the fire alarm system is tested in accordance with an approved program complying with the requirements of NFPA 101 (2012 edition), Sections 19.3.4 and 9.6.1, NFPA 70, National Electric Code (2011 edition), and NFPA 72, National Fire Alarm and Signaling Code (2010 edition) Section 14.4.5.3, 14.4.5.3.1 and 14.4.5.3.2. This deficient practice could affect all 3 patients and an undetermined number of staff and visitors.

Findings include:

On 07/10/18 at 11:51 am, it was noted during a review of the annual fire alarm system test/inspection report documents that there was no written record of the smoke detectors sensitivity range or measured sensitivity.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff Q, Staff R and Staff S.

Based on observation 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 5.2.1. This deficient practice could affect all 3 patients and an undetermined number of staff and visitors.

Findings include:

1. On 07/10/18 at 1:06 pm, observation revealed that a sprinkler in the nurse work room, which is open to the inpatient corridor, was not kept free of lint and other foreign material.
2. On 07/10/18 at 1:22 pm, observation revealed that the sprinkler heads in the juice room were not kept free of lint and other foreign material.
3. On 07/10/18 at 2:10 pm, observation revealed that the sprinkler head in the Emergency Department corridor near the EMT room was not kept free of lint and other foreign material.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff Q, Staff R and Staff S.

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

FINDINGS INCLUDE:
1. On 07/10/18 at 1:15 pm, observation revealed that the corridor doors to the inpatient staff only corridor were both blocked by laundry carts and the west door did not fully close and latch.
2. On 07/10/18 at 2:05 pm, observation revealed that the double corridor doors to the emergency department by rooms #3 and #4 did not fully close and latch.
3. On 07/10/18 at 2:27 pm, observation revealed that the corridor door to the clinic suite #2 did not fully close and latch.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff Q, Staff R and Staff S.

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments, in accordance with the requirements of NFPA 101 (2012 edition.), 19.3.7.8. This deficient practice could affect undetermined number of patients, staff and visitors.

Findings include:

1. On 07/10/18 at 1:53 pm, observation revealed in the basement corridor, the smoke barrier doors located by the boiler room and air handler 3, 4 &5 room, did not fully close.
2. On 07/10/18 at 2:02 pm, observation revealed in the Emergency Department rated cross corridor doors located by the stairs did not fully close.
3. On 07/10/18 at 2:27 pm, observation revealed in the smoke barrier doors in the outpatient surgery corridor, near the endoscopy rooms, were held open with friction hold open devices and not magnets tied into the fire alarm system.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff Q, Staff R and Staff S.