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Based on observation and interview, the facility failed to separate hazard areas from the remainder of the building by allowing unsealed penetrations in the walls and ceilings. This deficient practice could cause smoke and hot gases to migrate into the corridor affecting all occupants in 3 of 4 smoke compartments (Patient Wing, Emergency/Surgery, and Imaging).

Findings are:

Observations on 7-13-2022 between 11:20 AM and 11:51 AM revealed the following:

1) The sprinkler riser room had two unsealed pipe penetrations in the west wall.
2) Janitor closet in surgery next to "prep and hold" room had a hole in the back wall.
3) Electrical room #1315 by nurse station had multiple unsealed pipe and conduit penetrations in the walls.

During interviews on 7-13-2022 between 11:20 AM and 11:51 AM, Maintenance Staff confirmed the findings.

Based on observation and staff interview, the facility failed to provide a complete ceiling assembly in 1 of 4 smoke compartments (Imaging) by allowing multiple ceiling tiles to be removed. This deficient practice did not ensure smoke and gasses would be kept below the ceiling to activate the fire sprinkler system and would cause the system to fail to operate as designed affecting all building occupants.

Findings are:

Observations on 7-13-2022 at 11:27 AM revealed the following:

1) Several ceiling tiles were missing in the IT Office.

During an interview on 7-13-2020 at 11:27 AM, Maintenance Staff confirmed the finding.

Based on record review and staff interview, the facility failed to conduct fire drills or emergency orientation training quarterly on each shift at varied times under varying conditions and staffing levels. This deficient practice would not provide simulated training for staff response in the event of a fire. This deficient practice affected all occupants.

Findings are:

Record review on 7-13-2022 at 10:37 AM revealed the following:

1) Facility conducted 7 of 7 drills on 1st shift at: 7:00 pm, 11:50 am, 7:00 pm, 3:00 pm, 11:50 am, 12:00 pm, and 10:35 am.
2) Facility conducted 5 of 5 drills on 2nd shift at: 7:00 pm, 7:00 pm, 10:15 pm, 00:00 am, and 11:30 pm.

During an interview on 7-13-2022 at 10:37 AM, Maintenance Staff confirmed the findings.

Based on observations and staff interview, the facility failed to ensure electrical receptacle boxes were equipped with cover plates. This deficient practice could cause a fire or burn upon accidental contact. The deficient practice would affect all occupants in 1 of 4 smoke compartments (Emergency/Surgery).

Findings are:

Observations on 7-13-2022 at 11:41 AM revealed the following:

1) An electrical junction box was missing a cover in the data closet #1207 by the nurse station.

During an interview on 7-13-2022 at 11:41 AM, Maintenance Staff confirmed the finding.