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Based upon observation and interview, the facility failed to ensure that doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area were self-closing and kept in the closed position unless held open in accordance with 7.2.1.8.2 as required by 19.2.2.2.7 and 19.2.2.2.8. This deficient practice could affect all occupants in each smoke compartment.

Findings Include:
On 01/08/2019 at approximately 10:10 AM South 1st floor pods 1, 2, 3, 4 self closing devices for the patient stairs were observed removed.
On 01/08/2019 at approximately 12:40 PM East 2nd floor pods 1, 2, 3, 4 self closing devices for the patient stairs were observed removed.

The above stated violations were observed and confirmed with staff #1.

Based upon observation and interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having a 1-hour fire-resistance rating or protected by an automatic extinguishing system in accordance with 8.7.1 as required by 19.3.2.1. This deficient practice could affect all occupants in each smoke compartment.

Findings Include:
On 01/08/2019 at the following times, the following violations were observed and confirmed with staff member #1
10:10 AM E3/E4 housekeeping closet door did not provide a positive latch.
10:20 AM E3/E4 linen room door 205 and frame rating labels were unreadable.
10:22 AM E3/E4 Soiled utility room door 211 and frame rating labels were unreadable.

Based upon observation and interview, the facility failed to ensure that automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 and records are readily available as required by 9.7.5, 9.7.7, 9.7.8, and NFPA 25. This deficient practice could affect all occupants in each smoke compartment.

Findings Include:
On 01/08/2019 at the following times the following observations were made with staff member # 1
10:50 AM East 1 pod E1 the sprinkler head under the lower landing was covered with paint.
11:00 AM East 1 pod E2 the sprinkler head under the lower landing was covered with paint.
1:00 PM East 1 pod E3 the sprinkler head under the lower landing was covered with paint.

Based upon observation and interview, the facility failed to ensure that portable fire extinguishers are selected, installed, inspected and maintained in accordance with NFPA 10 as required by 19.3.5.12. This deficient practice could affect all occupants in each smoke compartment.

Findings Include:
On 01/08/2019 at the following times the following violations were observed and confirmed with staff member # 1
10:35 AM The fire extinguisher cabinet for East 1 first floor pod E1 across from medication room 115 would not open.
12:50 PM The fire extinguisher cabinet for East 1 first floor pod E3 across from medication room E3 115 would not open.

Based upon observation and interview, the facility failed to ensure that smoke barriers were constructed to a minimum 1/2-hour fire resistance rating in accordance with 8.5 as required by 19.3.7.3 and 8.6.7.1(1). This deficient practice could affect all occupants in each smoke compartment.

Findings Include:
On 01/08/2019 the following times the following observations were made and confirmed with staff member #1
10:45 AM a incorrect penetration seal was observed above the smoke barrier doors for South 2.
10:55 AM a unsealed penetration was observed above the smoke barrier doors in the smoke barrier wall for South 3 first floor.
10:00 AM a unsealed penetration was observed above the smoke barrier doors in the smoke barrier wall for South 4 first floor.

Based upon records review and interview, the facility failed to ensure that fire drills includes the transmission of a fire alarm signal, simulation of emergency fire conditions, are held at unexpected times under varying circumstances, and conducted at least quarterly on each shift as required by 19.7.1.4 through 19.7.1.7. This deficient practice could affect all occupants in all smoke compartments Findings Include:

On 01/07/2019 at approximately 9:45 AM during the review of records the following violation was observed. This was observed and confirmed with staff member # 2
Fire drill times for the 4th quarter did not vary in time.