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Based on observation and staff interview the facility failed to maintain a separation wall as described the Life Safety Code (NFPA 101) 2012 edition section 19.1.3.2. This deficient practice could allow for the spread of fire and smoke affecting all patients, staff and visitors.

Findings include:

On the facility tour between 7:30 am to 12:00 pm on 08/15/2018, observations revealed a 1 inch penetration of the smoke barrier above the ceiling at the elevator shaft.

This deficient condition was confirmed by the Maintenance Supervisor.

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 visitor and staff.

Findings include:

On the facility tour between 7:30 am to 12:00 pm on 08/15/2018, observations and staff interview revealed multiple smoke detectors with 36 inches of an HVAC diffuser:

1) Soiled Utility Room in the south corridor of the patient wing.
2) Throughout the Radiology Department.
3) Throughout the Clinic.

This deficient condition was confirmed by the Maintenance Supervisor.

Based on observation and staff interview, the facility failed to test and 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 all of the 25 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 7:30 am to 12:00 pm on 08/15/2018, observations revealed in the occupational therapy are a ceiling tile is not in place due to exercise equipment.

This deficient condition was confirmed by the Director of Maintenance.

Based on observation and staff interview the facility failed to maintain the Fire Extinguishers in accordance NFPA 101 (2012) Life Safety Code Section 9.7.4.1 and NFPA 10. This deficient practice could hinder the extinguishment of a small fire and could affect all patients and an undetermined amount of visitors and staff.

FINDINGS INCLUDE:

On facility tour between 8:00 AM to 5:00 PM on 06/12/2018, observations and staff interview revealed the fire extinguisher distance is exceeded in the corridor serving the Heritage Room.


This deficient condition was verified by a Maintenance Supervisor.

Based on record review and staff interview the facility failed to maintain smoke dampers in accordance with The Standard for Fire Doors and Other Opening Protective's, NFPA 80 , 2010 edition section 19.4.1.1. This deficient practice could allow smoke to travel throughout smoke compartments affecting the exiting capabilities of all patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 7:30 am to 12:00 pm on 08/15/2018, observations revealed a 2-hour fire barrier at the clinic registration area had a 20 minute door when a 90 minute door is required.

This deficient condition was confirmed by the Maintenance Supervisor.

Based on observation and staff interview the facility failed to properly store soiled linen and trash containers in a protected hazardous room as stated in the Life Safety Code NFPA 101 2012 edition section 19.7.5.7. This deficient practice could affect the safety of 25 of the 25 patients and an undetermined amount of staff and visitors if smoke or fire from one of these containers made the corridors non-useable.

Findings include:

On the facility tour between 7:30 am to 12:00 pm on 08/15/2018, observations and staff interview revealed trash carts over 32 gallons were being stored in a non hazardous room in all patient wings.

This deficient condition was confirmed by the Maintenance Supervisor.

Base on observation the facility failed to document the maintenance inspection report for the piped gases as per NFPA 99 (2012) 5.1.14.2.1. This deficient practice could affect the safety of 25 of the 25 patients and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 7:30 am to 12:00 pm on 08/15/2018, observations and staff interview revealed there is no scheduled maintenance program for the piped in oxygen.

This deficient condition was confirmed by the Maintenance Supervisor.