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Based on review of the facility schematic, tour of the facility and staff interview and confirmation, the facility failed to ensure that if the building had a common wall with a nonconforming building, the common wall was a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition. The census was nine patients at the time of survey.

Findings include:

Review of facility schematic on 06/16/15 revealed the presence of a two hour fire rated barrier wall between the hospital and the surgery center. The surgery center construction type was noted as II(000) and the hospital construction type was identified as II(111). Both facilities were provided automatic sprinkler protection.

Tour of the facility was conducted with Staff AA on 06/16/15 between 10:33 A.M. and 11:30 A.M. Observation of the two hour fire rated wall above the ceiling tiles revealed penetrations in the following areas:

1. Located in the consult room for the ambulatory surgery center, a penetration surrounding black sprinkler system pipe.

2. Located in the on-call room B126, an area approximately 12 feet in length at the roof decking that was not sealed.

3. Located in on-call room B125, an area approximately 10 feet in length that was not sealed at the roof decking.

4. Located in the patient bathroom, spaces surrounding a three inch pipe, four conduits, and two additional pipes approximately two inches in diameter that were not sealed.

5. Located in the patient holding room for ambulatory surgery, approximately 10 feet of the barrier wall was not sealed at the roof decking. Additionally, a rug in the walkway prevented the fire rated door within the two hour fire rated wall from closing. When the door was pulled shut, the door failed to securely latch.

Staff AA present on the tour confirmed the findings.

Based on observation and staff interview the facility failed to maintain it smoke barriers from the passage of smoke. This had a potential to affect all patients, staff, and visitors. The census was nine patients at the time of survey.

Findings include:

1. At 10:32 AM on 06/16/15 observation above the ceiling tiles at the smoke barrier doors on the second floor, across from patient room A 216, a 3 inch conduit sleeve, with white and blue wires passing through, did not have fire stop inside the open space. The finding was confirmed at the time of discovery by Staff DD and EE.

2. At 11:34 AM on 06/16/15 observation above the ceiling at the smoke barrier doors on the second floor across from patient room A 204 two angle iron supports penetrated the smoke barrier with a gap noted around the supports. The finding was confirmed at the time of discovery by Staff DD and EE.

Based on observation and staff interview the facility failed to maintain an intact one hour fire wall around the hazardous areas. This had a potential to affect all patients, staff, and visitors. The census was nine patients at the time of the survey.

Findings:

1. At 10:27 AM on 06/161/5 observation above the ceiling tiles, on the second floor inside soiled utility, room A 224, revealed five 1/2 conduit with blue data lines passing through them that did not contain fire stop material in the ends. Staff DD and EE confirmed the findings at the time of discovery.

2. At 10:32 AM on 06/16/15 observation above the ceiling tiles on the second floor inside room A 225 clean utility room revealed one 1/2 inch conduit not sealed at the end. Staff DD and EE confirmed the findings at the time of discovery.

3. At 1:57 PM on 06/16/15 observation above the ceiling tiles on the first floor outside the dietary storage room A 115 at the exit access revealed a 1/2 conduit with a blue data wire passing through, not sealed at the end. Staff DD and EE confirmed the findings at the time of discovery.

4. At 2:06 PM on 06/161/15 observation above the ceiling tiles inside the dietary office A 116 revealed 2 inch conduit not sealed at the end. Staff DD and EE confirmed the findings at the time of discovery.

5. At 2:25 PM on 06/16/15 observation above the ceiling tiles in the corridor outside general stores revealed two, 1/2 inch conduit not sealed at the end and two conduit with a open gap noted around the conduit. Staff DD and EE confirmed the findings at the time of discovery.

6. At 3:17 PM on 06/16/15 observation above the ceiling tiles on the cafe side of the kitchen wall revealed pentrations in the wall with wires passing through not sealed. Staff DD and EE confirmed the findings at the time of discovery.

7. At 3:45 PM on 06/16/15 observation above the ceiling tiles outside the medical records room revealed the area was open to the rest of the occupancy. The medical records room was found to contain approximately 12 movable shelving units with a large amount of paper charts stored there. During interview with Staff AA it was confirmed the facility stored large quantities of paper medical records in the room. Staff DD and EE confirmed the findings at the time of discovery.

1. Medical gas storage and administration areas are protected in accordance with NFPA 99, Standards for Health Care Facilities, and NFPA 101.

(a) Oxygen storage locations of greater than 3,000 cu. ft. are enclosed by a one hour separation.

Based on review of facility schematics, facility observation and staff interview and confirmation, the facility failed to ensure the oxygen storage location of greater than 3,000 cu. ft. was enclosed by a one hour separation. The facility census was nine patients at the time of survey.

Findings include:

On 06/16/15 between 1:25 P.M. and 3:45 P.M., tour of the facility was conducted with Staff AA. Review of the facility schematics revealed the medical gas storage room was enclosed with one hour fire rated construction. Observation of the medical gas storage room revealed storage significantly greater than 3000 cubic feet of medical gas storage. The door to the room was a metal door with no identifiable fire rating.

Staff A present at the observation, confirmed there was no noted fire rating on the door to the medical gas storage room.

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2.

38.3.2.
Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

8.4 SPECIAL HAZARD PROTECTION
8.4.1 General.
8.4.1.1*
Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.

8.2.3.2 Fire Protection-Rated Opening Protectives.
8.2.3.2.1
Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Based on review of facility schematics, facility observation and staff interview and confirmation, the facility failed to ensure the electrical panel location was enclosed by a one hour separation. The facility census was nine patients at the time of survey.

Findings include:

On 06/16/15 between 1:25 P.M. and 3:45 P.M., tour of the facility was conducted with Staff AA. Review of the facility schematics revealed the electrical room for the facility was enclosed with one hour fire rated construction. Observation of the electrical room revealed the door to the room was a metal door with no identifiable fire rating. Additionally, the metal door to the room was noted to have a self-closing device but was held open using a block of wood.

Staff AA present at the observation, confirmed there was no noted fire rating on the door to the electrical room. Staff AA also confirmed the door to the room was not to be held open with a piece of wood.