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Based on observation and interview, the facility did not provide a common separation wall with sealed wall penetrations, as required by with NFPA 101 (2012 edition), 19.1.3.5; and 8.2.1.3. This deficiency had the potential to affect an undetermined number of out- patients, staff, and visitors.

FINDINGS INCLUDE:

On 01/08/2019 at 9:20 am, it was observed in the Out Patient smoke compartment on the second floor in the corridor to the Medical Office Building at the 2 hour wall above the ceiling, that penetrations were not properly fire stopped according to an approved method. The deficiency included (2) 1" diameter red conduits that were not properly fire stopped. The condition was confirmed at the time of discovery by a concurrent interview with staff P (Plant/Facilities Project Manager), staff Q (Plant/Facilities Project Manager), staff R (Maintenance Mechanic), staff S (Plant Services Supervisor), and Staff T (Environment of Care Coordinator).
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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 101 (2012 edition) 19.3.5, and 9.7, and NFPA 13 (2010 edition) 8.1 requirements with all rooms sprinkled when the code required full sprinkling. This deficiency had the potential to affect all of the 8 patients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 01/08/2019 at 10:10 am, it was observed in the Med Surge smoke compartment on the second floor in the electrical closet N243, that the electrical closet was not sprinkler protected. The condition was confirmed at the time of discovery by a concurrent interview with staff P (Plant/Facilities Project Manager), staff Q (Plant/Facilities Project Manager), staff R (Maintenance Mechanic), staff S (Plant Services Supervisor), and Staff T (Environment of Care Coordinator).
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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations as required by NFPA 101 (2012 edition), 19.3.7.3., and 8.5. This deficiency had the potential to affect an undetermined number of out- patients, staff, and visitors.

FINDINGS INCLUDE:

1. On 01/07/2019 at 3:25 pm, it was observed in the Food Service smoke compartment on the first floor in the corridor above the ceiling at the smoke wall to admitting smoke compartment, that penetrations were not properly fire stopped according to an approved method. The deficiencies included (2) 3/4" diameter conduits, that were not properly fire stopped. The condition was confirmed at the time of discovery by a concurrent interview with staff P (Plant/Facilities Project Manager), staff Q (Plant/Facilities Project Manager), and staff R (Maintenance Mechanic).
2. On 01/08/2019 at 9:00 am, it was observed in the Administrative smoke compartment on the second floor in the corridor above the ceiling at the smoke wall to the Outpatient smoke compartment, that penetrations were not properly fire stopped according to an approved method. The deficiencies included (2) 4" diameter conduits with data wires and (5) 1" diameter conduits that were not properly fire stopped. The condition was confirmed at the time of discovery by a concurrent interview with staff P (Plant/Facilities Project Manager), staff Q (Plant/Facilities Project Manager), staff R (Maintenance Mechanic), staff S (Plant Services Supervisor), and Staff T (Environment of Care Coordinator).
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Based on record review and interview, the facility did not conduct fire drills as required by NFPA 101 (2012 edition), 19.7.1.6., to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency had the potential to affect all of the 8 patients, as well as an undetermined number of out- patients, staff, and visitors.

FINDINGS INCLUDE:

On 01/07/2019 at 2:15 pm, record review revealed that the facility fire drill records were missing for the first shift first Quarter and the second shift second Quarter. Fire drills were conducted in a pattern so they were not always at unexpected times. On the third shift the second Quarter drill was 6:05 am and the third Quarter was at 6:14 am. The condition was confirmed at the time of discovery by an interview with staff P (Plant/Facilities Project Manager), staff Q (Plant/Facilities Project Manager), staff R (Maintenance Mechanic), and staff S (Plant Services Supervisor).
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Based on record review and interview, the facility did not conduct fire drills as required by NFPA 101 (2012 edition), 19.7.1.6., to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency had the potential to affect all of the 8 patients, as well as an undetermined number of out- patients, staff, and visitors.

FINDINGS INCLUDE:

On 01/07/2019 at 2:15 pm, record review revealed that the facility fire drill records were missing for the first shift first Quarter, and the second shift second Quarter. Fire drills were conducted in a pattern so they were not always at unexpected times. On the third shift the second Quarter drill was 6:05 am, and the third Quarter was at 6:14 am. The condition was confirmed at the time of discovery by an interview with staff P (Plant/Facilities Project Manager), staff Q (Plant/Facilities Project Manager), staff R (Maintenance Mechanic), and staff S (Plant Services Supervisor).
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Based on record review and interview, the facility did not conduct fire drills as required by NFPA 101 (2012 edition), 19.7.1.6., to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency had the potential to affect all of the 8 patients, as well as an undetermined number of out- patients, staff, and visitors.

FINDINGS INCLUDE:

On 01/07/2019 at 2:15 pm, record review revealed that the facility fire drill records were missing for the first shift first Quarter, and the second shift second Quarter. Fire drills were conducted in a pattern so they were not always at unexpected times. On the third shift the second Quarter drill was 6:05 am, and the third Quarter was at 6:14 am. The condition was confirmed at the time of discovery by an interview with staff P (Plant/Facilities Project Manager), staff Q (Plant/Facilities Project Manager), staff R (Maintenance Mechanic), and staff S (Plant Services Supervisor).
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