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Based on visual observation the facility failed to assure that all doors within an exit passageway were held open by an approved means would close properly when released. When doors to stairwells, smoke barriers, horizontal exits or hazardous areas do not close properly it provides an opportunity to allow fire and/or smoke to flow freely throughout the facility. This deficient practice has the potential to affect 20 of 80 residents.

Findings:

During the facility tour, between the hours of 8:00AM to 4:00PM on dates of 1/19 to 1/20/2017 it was observed that when the doors on the first floor by the lab had the hold opens released the right hinged door did not go to and remain in the closed position.

Interview with the maintenance director revealed the facility was not aware that the door was not able to close properly.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 40 of 80 residents.
4 of 10 smoke compartments have hazardous areas that are not separated.

Findings:

During the facility tour, between the hours of 8:00AM to 4:00PM on dates 1/19 through 1/20/2017 it was observed that the closet in room 105, the old chapel on the first floor, flammable liquids being stored in the laundry building, and the 3rd floor mechanical room by room 322 were being used for storage without having the proper construction and/or no self-closures

Interview with the maintenance director revealed the facility was not aware of the hazardous areas that had been created and that the areas were required to have doors that self-close and latch in the frame. .

Based on visual observation the facility failed to assure that the fire alarm system was installed to provide effective warning to all parts of the building. The devices installed for the system ' s activation shall be by manual, detection or extinguishing operation which gives a sense of security to offer an advance warning in an emergency. This deficiency could potentially affect 80 of 80 residents.

Findings:

During the facility tour and the record review, between the hours of 8:00AM to 4:00PM on dates 1/19-1/20/2017 it was observed that smoke detectors had been installed less than 3 feet from air ducts on the 1st floor elevator near the new gift shop, in the ER by exam 15, and the 2nd floor IT room. No strobes were installed in the OR Core bathroom.

Interview with the maintenance director revealed the facility was not aware that additional devices, such as, the (tamper switch, visual device, pull station, smoke detector, etc.) were needed and that the smoke detectors were installed within 3 feet of air ducts.

Based on visual observation the facility failed to assure that the supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 80 of 80 residents.

Findings:

During the facility tour, between the hours of 8:00AM to 4:00PM on dates of 1/19 through 1/20/2017 it was observed that sprinkler heads on the 3rd floor east tower on the back wall had been sprayed with a fire retardant coating for the beams and also had multiple heads that were dirty. The sprinkler heads on the first floor in the elevator lobby from the main entrance by the new gift shop had multiple heads that were no longer perpendicular and had also recessed back into the ceiling. On the 2nd floor in the EKG oxygen room the sprinkler head was dirty. In the basement area of the old chillers one head was installed against duct equipment. The 1st floor air handling room by radiology did not have proper coverage due to greater than 4 foot obstructions. The sprinkler riser in the laundry room was damaged and observed a spraying leak from the piping. The combustible storage shed did not have proper coverage for the hazard present.

Interview with the maintenance director revealed the facility was not aware that during the annual and/or quarterly inspections that the proper maintenance had not been conducted on these areas of the automatic sprinkler system.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 40 of 80 residents. 5 of 10 smoke barriers were deficient.

Findings:

During the facility tour, between the hours of 8:00AM to 4:00PM on dates 1/19 through 1/20 it was observed that penetrations through smoke and fire barriers were at the following areas; 1st floor at ER by Exam Room 15 on both sides of wall, 1st floor by old gift shop, 1st floor at fire wall separating the sprinklered building from the none sprinklered building, 2nd floor by ICU and Cardiology, and 3rd floor east tower along the wall to the left of the elevators.

Interview with the maintenance director revealed the facility was not aware of unsealed penetrations.

Based on visual observation of a fire drill the facility failed to maintain the staff familiarity with the procedures of a fire drill. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 80 of 80 residents.

Findings:

During the facility tour, between the hours of 8:00AM to 4:00PM on dates 1/19 through 1/20/2017 it was observed during two separate fire drills one on the 3rd floor and one on the 2nd floor that staff was unaware of the procedures that they needed to perform by.

Interview with maintenance director revealed the facility was not aware that during the fire drills the staff was not being properly trained on the procedures to follow.

Based on visual observation the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110 . In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 80 of 80 residents.

Findings:

During the facility tour, between the hours of 8:00AM to 4:00PM on dates 1/19 through 1/20/2017 it was observed that no remote manual stop for the generators had been provided.

Interview with the maintenance director revealed the facility was not aware that a remote manual stop for emergency generators was required.