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Based on observation and staff interview the facility failed to maintain the rated construction of a 2 hour fire barrier as described in NFPA 101 (12) Life Safety Code section 8.3.1.2 (2). This deficient condition could allow for the spread of fire or smoke into other compartments affecting all patients, staff and visitors.

Findings include:

On the facility tour between 7:30 am to 10:30 am on 03/07/2018 observations revealed a conduit, that penetrated a 2 hour fire barrier above the cross corridor doors at Lobby 2, was not properly fire stopped.

This deficient condition was confirmed by Assistant 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 and an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 7:30 am to 10:30 am on 03/08/2018 observations and staff interview revealed smoke detectors in the following locations were installed less than 36 inches from an HVAC diffuser.
1. Rooms 101, 181, 183, 300
2. At the ER entrance
3. In the scheduling office
4. In the radiology corridor
5. In the entrance to the fitness center.
6. By lobby 2 entrance.


This deficient condition was confirmed by Assistant Maintenance Director.

Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the Fire Alarm system has to be placed out-of-service for four or more hours in a 24 hour period as per NFPA 101 2012 edition section 9.6.1.6. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of all 25 patients as well as an undetermined number of staff, and visitors.

Findings include:

On the facility tour between 7:30 am to 10:30 am on 03/08/2018 record review and staff interview revealed the fire alarm out of service policy did not contain a statement stating that a fire watch shall be conducted if the fire alarm is out of service for more than 4 hours in a 24 hour period.

This deficient condition was confirmed by Assistant Maintenance Director.

Based on a record review and staff interview, the facility has failed to provide a complete and acceptable written policy containing procedures to be followed in the event that the automatic fire sprinkler system has to be placed out-of-service for ten or more hours in a 24 hour period as per NFPA 25. This deficient practice could affect the facility's ability for early response and notification of a fire and would affect the safety of all 25 patients as well as an undetermined number of staff, and visitors to the facility .


Findings include:


On the facility tour between 7:30 am to 10:30 am on 03/08/2018 record review and staff interview revealed the fire sprinkler out of service policy did not contain a statement stating that a fire watch shall be conducted if the fire sprinkler system is out of service for more than 10 hours in a 24 hour period.

This deficient condition was confirmed by Assistant Maintenance Director.

Based on observation and staff interview the facility failed to maintain two 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 an undetermined amount of patients, staff and visitors.

Findings include:

On the facility tour between 7:30 am to 10:30 am on 03/08/2018 observations and staff interview revealed improperly fire stopped penetrations in the following locations.

1. The smoke barrier next to room 501 above the cross corridor doors, a 2 inch by 5 inch opening.
2. The smoke barrier next to room 601 above the cross corridor doors, a 4 inch cable opening.

This deficient condition was confirmed by Assistant Maintenance Director.

Based on observation and staff interview, the facility has failed to provide a complete and current facility Risk Assessment in accordance with the NFPA 99 "Health Care Facilities Code" 2012 edition section 4.1. This deficient practice could affect all patients, as well as an undetermined number of staff, and visitors.


Findings include:

On the facility tour, between 7:30 am to 10:30 pm on 03/08/2018, during record review the facility was not able to provide a risk assessment document based on NFPA 99.

This deficient condition was confirmed by Assistant Maintenance Director.

Based on observation and staff interview the facility failed to ensure a multiple outlet connection was in accordance with the 2012 edition of NFPA 99 section 10.2.3.6 item 2 for total ampacity. This deficient practice could cause an overload of a circuit which could cause a power outage to necessary equipment or cause a fire. This could affect an undetermined amount of staff and visitors.

Findings include:

On the facility tour between 7:30 am to 10:30 am on 03/08/2018 observations and staff interview revealed several cooking appliances plugged into a power strip in the ambulance garage.

This deficient condition was confirmed by Assistant Maintenance Director.