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Based on record review and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 9.7.5 and NFPA 25 - 2011 edition, Sections 5.1.1.2. This deficient practice could affect all of the patients, plus an undetermined number of staff and visitors.

Findings include:

On 4/24/18 at11:22 am, it was noted during a review of the most recent fire sprinkler system inspection/test reports that there had not been a five year inspection and testing of the sprinkler system since 7/30/2012.

This condition was confirmed at the time of discovery by a concurrent interview with staff G.

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments, in accordance with the requirements of NFPA 101 (2012 edition.), 19.3.7.8. This deficient practice could affect an undetermined number of staff and visitors.

Findings include:

1. On 4/24/18 at11:41 am, observation revealed in the main admin corridor, that the cross corridor smoke barrier doors, adjacent to the health information department, did not fully close.
2. On 4/24/18 at11:41 am, observation revealed that the smoke barrier door to the administration offices, next to the break room, did not fully close.

These conditions were confirmed at the time of discovery by a concurrent interview with Staff G.

Based on record review, observation and interview, the facility did not provide a ventilation system in accordance with NFPA 101 (2012 ed.), 19.5.2.1, 9.2 and NFPA 90A, (2012 ed.) 2-3.11.1 and 4.3.12. This deficient practice could affect all of the patients, plus an undetermined number of staff and visitors.

Findings include:

1.On 04/24/18 at 9:51 am, it was noted during observation and review of documents that dampers were missing at the following locations:
a. The penthouse air handling unit, AC #2, which feeds the hospital wing, had main supply and return ducts that did not have fire dampers at the bottom of their respective masonry shafts that extended from the penthouse, through the 4th & 2nd levels to a crawl space located below the 2nd level.
b. Approximately 20 duct penetrations through the level 2 floor did not have fire dampers. The 5 " x12 " ducts in the crawl space passed through the level 2 floor, without dampers, to feed the floor mounted ventilation units on that floor. These ducts exceeded the maximum size permitted by the exception in the section to not have fire dampers.
c. About 6-8 supply and return ducts did not have fire dampers where they penetrated the penthouse and 4th level floors to serve the overhead ventilation grills on the 2nd level in the center core of the hospital space located below the footprint of the penthouse.

2. On 04/24/18 at 9:51 am, observation revealed during a walk-through of the facility that the two offices and the kitchenette were not provided with a supply grille within each room. Only a return air grille was installed within these rooms. The supply air was being taken from the corridor and transferred under the doorway; this required the ventilation system to use the corridor as a plenum for supplying air to these rooms.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff G. Staff G also stated that the air handlers shut down upon activation of the fire alarm system and the facility is equipped with a smoke control system.