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Based on observation and staff interview it was determined the facility failed to maintain automatic sprinkler system supervisory attachments on the three valves of the backflow preventer and the water control valve to the fire pump.

This could place 35 patients at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on 06/12/2018 between 8:00 AM and 3:00 PM observation revealed that the three control valves on the backflow preventer located in the water vault and the water control valve to the fire pump were not properly supervised.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19, Section 19.3.5.1, Chapter 9, Section 9.7.2.1, 2010 NFPA 72, 17.16.1.1 through 17.16.1.4

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system as required.

This could place 35 patients at risk in the event of a fire.

The finding includes:

During a tour of the facility and staff interview with Staff M on 06/12/2018 between 8:00 AM and 3:00 PM it was observed that gauges for the fire sprinkler system and fire pump were outdated.

This finding was confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19, Section 19.3.5.1, Chapter 9, Section 9.7.5, and 2011 NFPA 25, Chapter 5, Section 5.3.2.1.

Based on observation and staff interview it was determined the facility failed to properly maintained fire extinguishers.

This could place 0 patients at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on 06/12/2018 between 8:00 AM and 3:00 PM observation revealed that the type K fire extinguisher in the kitchen did not have the proper placard posted above it.

This finding was confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, 19.3.5.12, 9.7.4.1, 2010 NFPA 10, 5.5.5.3

Based on observation and staff interview it was determined the facility failed to maintain smoke barrier walls with construction having a fire resistance rating of at least one-half hour.

This could place 5 patients at risk in the event of fire.

The findings include:

During a tour of the facility with Staff M on 06/12/2018 between 8:00 AM and 3:00 PM observation revealed that rated wall on the second floor in the MRI area (Room 16) had unsealed penetrations.

These findings were confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101 , Chapter 19, Sections 19.3.7.1, 19.3.7.3, Chapter 8 Sections 8.3.5, 8.5.2.1, 8.5.2.2, 8.5.7.4, 8.5.6.1, 8.5.6.2, 8.5.6.3, Chapter 4, Section 4.6.12.1

Based on observation and staff interview the facility was not properly securing power strips off of the floor.

This could place 35 patients at risk in the event of a fire.

The finding include:

Based on observation and staff interview on 06/12/2018 between 8:00 AM and 3:00 PM it was observed that power strips throughout the facility were not properly secured off of the floor.

This finding was confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 99, Chapter 10, Sections 10.4.2.1 through 10.4.2.3 and CMS S&C letter 14-46-LSC

Based on observation and staff interview it was determined that the facility failed to provide an Oxygen storage location precautionary sign readable from five feet with the wording as a minimum of "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING".

The deficiency could affect 5 patients in the event of a fire.

The finding includes:

During a tour of the facility with Staff M on 06/12/2018 between 8:00 AM and 3:00 PM observation and staff interview revealed that the following O2 storage areas in the facility did not have the required signage posted on the O2 storage areas doors.

1. Cardio/Pulmanary equipment area.

2. ICU Equipment Storage Room.

This finding was confirmed by Staff M at the time of discovery.

Reference: 2012 NFPA 101, Chapter 19, Section 19.3.2.4, Chapter 8, Section 8.7 and 2012 NFPA 99 Chapter 11, Sections 11.3.4.1 and 11.3.4.2