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Based on observations and interview, the facility failed to maintain a Type II (III) construction type in one location of the facility by allowing a penetration to be present. This effects 1 smoke zone in the hospital. The facility had a capacity of 213 patients and a census of 82 patients..

Findings include:

Observations and interview on 12-13-16 at approximately 9:34 am revealed a penetration (approximately 3 inches in size) located in the ceiling of the ICU Data Closet.

Maintenance Staff A verified this observation at the time of the inspection process.

Based on observations and interview, the facility failed to maintain 1 emergency light unit in proper working order. This affects 1 smoke zones, in the hospital. The hospital had a license capacity of 213 patients and a census of 82 patients.

Findings include:

Observations and interview on 12-13-16 at approximately 10:15 am revealed the emergency light unit located in the Linear Accelerator Office failed to illuminate on battery back-up when tested.

Maintenance Staff Member A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to maintain 1 hazardous room properly separated by failing to ensure the door to this room was properly rated. This affects 1 smoke zone in the hospital. The hospital had a license capacity of 213 patients and a census of 82 patients.

Findings include:

Observations and interview on 12-13-16 at approximately 9:21 am revealed the door to the 2nd Floor Clean Storage Room, which contained combustible storage items, failed to be 1 hour fire rated. The rating on this door indicated it was rated for 20 minutes.

Maintenance Staff A verified this observation at the time of the survey process.

A.
Based on observations and interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by improperly locating multiple smoke detectors. This affects staff and visitors that would be located in the smoke zone affected by this deficiency. The facility had a license of 213 residents and a census of 82 residents.

Findings include:

Observations and interview on 12-13-16 between the hours of 9:30 am and 11:45 am revealed the following:

1. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Break Room.

2. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of Room #203.

3. 2 smoke detectors were located closer than 3 feet from an air diffuser (HVAC) in the ceiling of Room #205.

4. 2 smoke detectors were located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the back hall of the DHC.

5. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of MRI Area Waiting Room B.

6. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the A and B Conference Room in the Administration area.

7. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Clean Storage Room #256.

8. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Clean Storage Room #229.

9. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the O.B Waiting Room.

10. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Outpatient Surgery Waiting Room.

11. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the corridor near the Surgery Waiting Room.

12. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the TCU Locker Room.

13. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the corridor near the TCU Locker Room.

14. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Physical Therapy Office.

15. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the corridor near the Case Manager's Office.

16. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the classroom that is located next to Room #126.

17. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Heart and Vascular corridor.

18. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Heart and Vascular Nourishment Room.

19. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Heart and Vascular Waterfall Pump Room.

20. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Emergency Room corridor near Exam Room #1.

21. A smoke detector was located closer than 3 feet from an air diffuser (HVAC) in the ceiling of the Emergency Room corridor near Exam Room #6.

Maintenance Staff A, B and C verified these observations during the survey process.

B.
Based on observations and interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by improperly mounting a smoke detector. This affects 1 smoke zone in the hospital. The hospital had a license of 213 patients and a census of 82 patients.

Findings include:

Observations and interview on 12-13-16 at approximately 11:07 am revealed a smoke detector that was improperly mounted (hanging from the ceiling) in the Basement Bio Hazard Storage Room.

Maintenance Staff A verified this observation during the survey process.

Based on observations and interview, the facility failed to maintain 2 portable fire extinguishers located within the building in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition by failing to have the extinguishers inspected on a monthly basis. This affects 2 smoke zones in the hospital. The hospital had a capacity of 213 residents and a census of 82 residents.

Findings include:

Observations and interview on 12-13-16 at approximately 10:10 am and 11:05 am revealed the following:

1. The fire extinguisher located in the Behavior Health corridor near Group Room B failed to be visually inspected during the month of November, 2016.

2. The fire extinguisher located in the Emergency Room corridor near Exam Room #22 failed to be visually inspected during the month of November, 2016.


Maintenance Staff Member A verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain 1 set of smoke barrier doors to close properly. This affects 2 smoke zones in the hospital. The hospital had a capacity of 213 patients and census of 82 patients.

Findings include:

Observation and interview on 12-13-16 at 9:45 am revealed the east leaf of smoke barrier doors numbered FD2A0007 failed to close and latch when tested.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to ensure the buildings emergency generator was properly equipped with a remote manual stop mechanism in accordance with the National Fire Protection Association (NFPA) Standard for Emergency and Standby Power Systems (Section 3-5.5.6), 2010 Edition. This deficient practice affects all the smoke zones in the hospital. The hospital had a license capacity of 213 patients and a census of 82 patients.

Findings include:

Observations and interview on 12-13-16 at approximately 11:40 am revealed the manual emergency shut off for the generator was located inside the generator panel. The manual shut off should be located a safe distance away from the generator and labeled.

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to provide proper storage of a compressed gas cylinder in accordance with NFPA 99. This affects 1 smoke zone in the hospital. The hospital had a capacity of 213 patients and a census of 82 patients.

Findings include:

Observations and interview on 12-13-16 at approximately 11:10 am revealed an Acetylene cylinder that was not secured in the Flammable Storage Room.

Maintenance Staff A verified this observation at the time of the survey process.