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Based on observations and interview, the facility failed to notify the Tennessee Department of Health and take appropriate action while a portion of the fire alarm system was out of service.

The finding included:

Observation on 12/17/18 at 9:34 AM, revealed the fire alarm panel was showing a trouble alarm for zone 11. Interview with maintenance staff member #2 revealed that zone 11 had been disabled from the fire alarm system on 11/30/18 due to problems with a duct detector. Zone 11 monitors the pharmacy, old rehab, med-surge waiting room, and the roof air handler unit. Disabling zone 11 caused those areas to be with out a fire alarm system. Interview with maintenance staff member #1 revealed the facility has not conducted a fire watch or made notifications to the authority having jurisdiction. During the interview, it was revealed that the facility was aware of the fire watch requirements but could not perform the duties because of layoffs and the facility's financial difficulties. It was also revealed that the fire alarm company would not make repairs to the system due to non-payment of services.

NFPA 101, 19.3.4.1 (2012 Ed), NPFA 101, 9.6.1.6 (2012 Ed)

This finding was verified by the maintenance director during the survey and was acknowledged by the administrator during the exit conference on 12/17/18.

Based on observations and interviews, the facility failed to maintain the smoke barriers. This deficient practice affected 9 of 9 smoke barrier walls.

The finding included:

1. Interview with maintenance staff member #1 on 12/17/18 at 9:30 AM, revealed the repairs to the smoke barrier walls that were previously cited during the licensure survey on 9/18/18 have not been completed due to the facility's financial problems and non-payment to the fire stopping contractor.

2. Observation on 12/17/18 at 9:55 AM, revealed the 1 hour rated smoke barrier wall by room 158 was not properly constructed and the following penetrations were not properly fire stopped:

a. Structural beams not sealed
b. 2 low voltage cable bundles
c. 6 -2 inch metal conduits
d. 4 - 1 1/2 inch metal conduits
e. 1 - 3 inch sprinkler pipe
f. 4 - 1 inch metal conduits
g. 1 - 1/2 inch metal conduit
h. 4 - 6 inch insulated pipes
i. 3 - 1 inch insulated pipes
j. 1 black cable bundle
k. 1 - 2x2 unused opening
l. 2 metal ducts
m. 3 copper med gas pipes
n. Wall not sealed at the deck
o. Portions of the wall are not constructed properly to the deck
p. Portions of the wall that join a shaft wall are not constructed properly

3. Observation on 12/17/18 at 10:06 AM, revealed the 1 hour rated smoke barrier wall by room 105 was not properly constructed and the following penetrations were not properly fire stopped:

a. Structural beams not sealed
b. 5 - 2 inch metal conduits
c. 4 - 6 inch insulated pipes
d. 2 - copper med gas lines
e. 1 - 1 inch metal conduit
f. 1 - 1/2 inch metal conduit
g. 2 - low voltage cable bundles
h. Wall not sealed at the deck
i. Portions of the wall are not constructed properly to the deck
j. Portions of the wall that join a shaft wall are not constructed properly
k. Blowout patches

4. Observation on 12/17/18 at 10:46 AM, revealed the 1 hour rated smoke barrier wall by pharmacy/waiting room contained the following penetrations that were not properly fire stopped:

a. 3 - 3 inch insulated pipes
b. 7 - 1 inch metal conduits
c. 3 - copper med gas lines
d. 2 - 6 inch insulated pipes
e. 7 - 1/2 inch metal conduits
f. 2 - 3 inch sleeves
g. 3 cable bundles
h. 1 - 2 inch sleeve
i. 7 unused openings
j. 1 metal duct
k. 4 - 2 inch metal conduits
l. Wall not sealed at the deck

5. Observation on 12/17/18 at 10:50 AM, revealed the 1 hour rated smoke barrier wall by the electrical room/dietitian room contained the following penetrations that were not properly fire stopped:

a. 8 - metal conduits
b. 4 blowout patches
c. Wall not sealed at the deck

6. Observation on 12/17/18 at 11:00 AM, revealed the 1 hour rated smoke barrier wall at the entrance of respiratory/cardiac rehab contained the following penetrations that were not properly fire stopped:

a. 3 - 1 inch metal conduits
b. 2 - 1/2 inch metal conduits
c. 1 - 2 inch sleeve
d. Blowout patches
e. Corner of the wall not constructed to the deck
f. An area of fire proofing is missing from the beam above the door
g. Wall not sealed at the deck

7. Observation on 12/17/18 at 11:10 AM, revealed the 1 hour rated smoke barrier wall by employee entrance to cafeteria
contained the following penetrations that were not properly fire stopped:

a. 5 - 1 inch metal conduits
b. 4 blowout patches
c. 3 metal flex conduits
d. Wall not sealed at the deck

8. Interview with the maintenance staff member #1 and #2 on 12/17/18 at 11:20 AM, revealed the 1 hour rated smoke barrier wall by the doctors lounge contained the same fire stopping issues as the other walls listed above and was also in need of repair.

9. Interview with the maintenance staff member #1 and #2 on 12/17/18 at 11:28 AM, revealed the 1 hour rated smoke barrier wall in the ER hallway by room 5 contained the same fire stopping issues as the other walls listed above and was also in need of repair.

10. Interview with the maintenance staff member #1 and #2 on 12/17/18 at 11:30 AM, revealed the 1 hour rated smoke barrier wall by the administration contained the same fire stopping issues as the other walls listed above and was also in need of repair.

NFPA 101, 19.3.7.3 (2012 Ed), NFPA 101, 8.5.6.2 (2012 Ed), NFPA 101, 8.5.6.3 (2012 Ed), NFPA 101, 8.3.5 (2012 Ed), NFPA 101, 8.3.5.1 (2012 Ed)

This finding was verified by the maintenance director during the survey and was acknowledged by the administrator during the exit conference on 12/17/18.

Based on interviews, the facility failed to maintain the emergency generator.

The finding included:

Interview with the maintenance staff members #1 and #2 on 12/17/18 at 11:40 AM, revealed the emergency generator was past due for the annual load bank and the generator company wouldn't perform the service due to non-payment.

This finding was verified by the maintenance director during the survey and was acknowledged by the administrator during the exit conference on 12/17/18.