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Based on observation and staff interview, the facility did not ensure that the range hood fire suppression system was installed and maintained as required per NFPA 101 - 2012 edition, Sections 19.3.2.5 through 19.3.2.5.5, 9.2.3; and NFPA 96 - 2011 edition, Sections 11.2.1, 11.4 and 11.6. This deficient practice could affect approximately three kitchen staff members and an undetermined number of outpatients, staff, and visitors.

Findings include:

On 4-18-2017 at 10:37 a.m., observation revealed that the serving kitchen had a range hood & exhaust system, but did not have a range hood fire suppression system which is also required to be tied into the fire alarm system. During a concurrent interview, staff MFS stated that they do create grease ladden vapors from the food they prepare.

Based on observation and staff interview, the facility did not ensure that the corridor doors were maintained in accordance with NFPA 101 (2012 edition), Sections 19.3.6.3, 19.3.6.3.2 and 19.3.6.3.5. This condition could affect all 4 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 4-18-2017 at 9:57 a.m., observation revealed that the inactive door of the double exit access corridor doors, serving the electrical panel room #1067 within the ER corridor, is equipped with a slide bolt at the head of the door that is manually secured to the head of the door frame. The active door is equipped with a lockset that positively latches into the inactive door. The inactive door does not automatically latch positively as required. This condition was confirmed at the time of discovery by a concurrent interview with staff MFS.

2. On 4-18-2017 at 9:58 a.m., observation revealed that the inactive door of the double exit access corridor doors, serving the storage closet room #1043 within the ER corridor, is equipped with a slide bolt at the head of the door that is manually secured to the head of the door frame. The active door is equipped with a lockset that positively latches into the inactive door. The inactive door does not automatically latch positively as required. This condition was confirmed at the time of discovery by a concurrent interview with staff MFS.

Based on observation and staff interview, the facility did not ensure that the fire resistance rating and smoke tightness of smoke barrier walls, with properly sealed penetrations, were maintained in accordance with NFPA 101 - 2012 edition, 19.3.7.3 and 8.5. This condition could affect all 4 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 4-18-2017 at 9:37 a.m., observation revealed a 2" pipe sleeve with multiple communication cables penetrated the gypsum board smoke barrier above the double corridor doors 1198 in corridor 1192. The penetration was not properly fire stopped in accordance with approved materials and methods. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff MFS.

2. On 4-18-2017 at 10:05 a.m., observation revealed multiple communication cables penetrated the gypsum board smoke barrier above the double corridor doors in the passage corridor 1115 by the "Imaging Room". The penetrations were not properly fire stopped in accordance with approved materials and methods because portions of the fire caulking was sagging and created unprotected gaps. This deficiency was confirmed at the time of discovery by a concurrent interview with Staff MFS.

3. On 4-18-2017 at 10:18 a.m., observation revealed multiple communication cables penetrated the gypsum board smoke barrier above the double corridor doors in the ED corridor by room 1081. The penetrations were not properly fire stopped in accordance with approved materials and methods because portions of the fire caulking was sagging and created unprotected gaps. This deficiency was confirmed at the time of discovery by a concurrent interview with Staff MFS.

4. On 4-18-2017 at 10:12 a.m., observation revealed a 1/2" copper oxygen gas pipe penetrated a 2 hour rated fire barrier above the lay-in ceiling at the Pharmacy room # 1067. Further observation revealed that the original fire caulk around the perimeter pulled away from the wall exposing the original gap. The penetration was not properly fire stopped in accordance with approved materials and methods. This deficiency was confirmed at the time of discovery by a concurrent interview with Staff MFS.

Based on record review and staff interview, the facility did not ensure that quarterly fire drills were held at unexpected times, once per each shift per quarter, and under varying conditions as required per NFPA 101 - 2012 edition, Sections 4.7.1, 4.7.2, 4.7.6, 19.7.1, 19.7.1.4 and 19.7.1.6. This condition could affect all 4 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 04-17-2018 at 11:37 a.m., review of available facility fire drill documents, for the previous calendar year, revealed that fire drills for the 2nd shift, 1st, 2nd, 3rd, & 4th quarters of 2017 all occurred within one hour of each other.The fire drill for 2nd shift, 1st quarter took place 2-22-2017 at 2:03 pm and the fire drill for 2nd shift, 2nd quarter took place 5-18-2017 at 2:04 pm. The fire drill for 2nd shift, 3rd quarter took place 9-28-2017 at 2:00 pm and the fire drill for 2nd shift, 4th quarter took place 11-30-2017 at 2:00 pm. The condition was confirmed at the time of discovery by a concurrent interview with Staff MFS.

2. On 04-17-2018 at 11:42 a.m., review of available facility fire drill documents, for the previous calendar year, revealed that fire drills for the 3rd shift, 1st, 2nd, 3rd, & 4th quarters of 2017 all occurred within one hour of each other. The fire drill for 3rd shift, 1st quarter took place 1-27-2017 at 5:23 am and the fire drill for 3rd shift, 2nd quarter took place 4-28-2017 at 5:06 am. The fire drill for 3rd shift, 3rd quarter took place 8-31-2017 at 5:15 am and the fire drill for 3rd shift, 4th quarter took place 11-16-2017 at 5:09 am. The condition was confirmed at the time of discovery by a concurrent interview with Staff MFS.