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Based on observation and interview, the facility failed to provide self-closing doors to provide a separation between hazardous areas and other spaces in accordance with NFPA 101 (2012 edition), Sections 19.3.21.2, 19.3.2.1.5(7), 8.4.3.5 and 7.2.1.8. These deficient practices could affect an undetermined number of patients, staff and visitors.

Findings include:

1. On 07/12/2022 at 12:05 pm, observation revealed that the Central Supply Storage Room in smoke compartment 0B on the lower/basement level did not have an automatic closing device for the room door.

2. On 07/12/2022 at 1:40 pm, observation revealed that vacant patient room 205 in smoke compartment 2A on the second floor south wing of the original 1963 constructed building was being used for storage of combustible materials and the room was greater than 50 square feet without a door that was self closing or automatic closing. The room was being used to store 100+ cardboard boxes filled with PPE supplies.

3. On 07/12/2022 at 1:41 pm, observation revealed that vacant patient room 206 in smoke compartment 2A on the second floor south wing of the original 1963 constructed building was being used for storage of combustible materials and the room was greater than 50 square feet without a door that was self closing or automatic closing. The room was being used to store 100+ cardboard boxes filled with PPE supplies.

These deficient practices were confirmed by Staff D and N at the time of discovery.

Based on observation and interview, the facility failed to install the automatic sprinkler system in accordance with NFPA 101 (2012 edition) Sections 19.3.5.1, 9.7.5, & 9.7.1.1; NFPA 25 (2011 edition) Sections 5.1.1.2, 5.2.1, & 14.2.1. These deficiencies could affect an undetermined number of staff and visitors.

Findings include:

1. On 07/12/2022 at 12:00 pm, observation in Central Supply Director Office in the 0B smoke compartment on the lower/basement level revealed a sprinkler head with missing escutcheon ring leaving 1/4" gap between sprinkler assembly and ceiling tile.

2. On 07/12/2022 at 12:02 pm, observation in Central Supply Storage Room in the 0A smoke compartment on the lower/basement level revealed that two (2) sprinkler head escutcheon rings were dropped down 1/4 inch below ceiling leaving a gap through the ceiling

3. On 07/12/2022 at 1:50 pm, observation in the north end corridor closet in the 2C smoke compartment on the second floor north wing in the original 1963 constructed building revealed two (2) 2 x 2 foot ceiling tiles popped out of the metal grid and laying on top of the grid in the ceiling space.

These deficient practices were confirmed by Staff D and N at the time of discovery.

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:

On 07/12/2022 at 11:43 am, observation revealed that the double smoke doors between 0B and 0C smoke compartments in the lower/basement level did not fully close and latch due to wood door warping.

This deficient practice was confirmed by Staff D and N at the time of discovery.