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Based on observation and staff interview, the facility did not ensure that the fire rated roof structure assembly, classified as Type II (1,1,1) Protected Noncombustible, is maintained in accordance with NFPA 101 (2012 edition), 19.1.6.1. This condition could affect all 21 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

On 2-14-17 at 9:39 am, observation revealed within the shell space on the second floor, located in the Surgery Center addition, that fire resistance rated fire proofing had been removed from the edge of numerous structural steel beams to accommodate placement of electrical conduit and electrical junction boxes. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff VV.

Based on observation and staff interview, the facility did not ensure that the stair shaft is maintained as a smokeproof enclosure in accordance with NFPA 101 (2012 edition), 19.2.2.4 and 7.2.3. This condition could affect all 21 inpatients and an undetermined number of outpatients, staff, and visitors.

Findings include:

On 2-14-17 at 10:45 am, observation revealed that within the stair shaft south of the Obstetrics suite on level 1, a sprinkler pipe approximately 2" in diameter, penetrated the east wall above the door. The penetration was not properly sealed in accordance with approved materials and methods. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff VV.

Based on observation and staff interview, the facility did not ensure that hazardous rooms were protected by a fire barrier having a 1-hour resistance rating or an approved automatic fire extinguishing system in accordance with NFPA 101 (2012 edition) 39.3.2.1 and 8.7.1 This condition could affect an undetermined number of outpatients, staff and visitors.

Findings include:

On 2-15-17 at 11:05 am, observation revealed that, the electrical room, located south of the large storage room on the first level of the attached medical clinic, was not sprinkler protected and that the corridor door to the electrical room had a fire rating of only 20 minutes. Further observation revealed that approximately 14 electrical conduits of vatious sizes up to 2", a bundle of communication wires, one 3/4" copper pipe, two 1 1/2" holes penetrated the walls. Additional observation revealed that the ceiling precast concrete slabs had three 3" cored holes through them that were penetrated with two 2" conduits and a bundle of communication wires. All of the penetrations were not properly sealed in accordance with approved materials and methods to maintain the required 1-hour fire resistance rating of the room. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff VV.

Based on observation and staff interview, the facility did not ensure that the 1-hour fire resistance rated hazardous room was maintained in accordance with NFPA 101 (2012 edition), 19.3.2.1. This condition could affect all 21 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 2-14-17 at 1:43 pm, observation revealed in the boiler room, located on the 1st level of the hospital, at the north entrance to the boiler room, that a 1- 1/2" sprinkler pipe penetrated the fire resistance rated wall above the door and was not properly sealed in accordance with approved materials and methods. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff VV.

2. On 2-14-17 at 3:11 pm, observation revealed in the storage room, located directly across the hallway from the materials management area on the north end of the lower level hospital, that a 1" x 1" square penetration on the west wall was not properly sealed in accordance with approved materials and methods. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff VV.

Based on record review, observation and staff interview, the facility did not ensure that the automatic sprinkler fire suppression system is properly maintained in accordance with NFPA 101 (2012 edition) 9.7.5, and NFPA 25 (2011 edition), 4.7, 5.2.1, and 5.3.2.1. This condition could affect all 21 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 2-13-17 at 3:00 pm, the most recent annual sprinkler system inspection report dated 8-15-16 was reviewed. The report did not indicate that gauges had been replaced within the past 5-years. On 2-14-17 at 11:10 am, observation revealed the orange maintenance tag on the sprinkler risers indicated that gauges were due to be replaced in January 2017. The condition was confirmed at the time of discovery by a concurrent record review, observation, and interview with Staff VV.

2. On 2-14-17 at 10:05 am, observation revealed within the second floor corridor, west of the atrium, two sprinkler heads, that provide coverage for the atrium windows, had paint on the head of the sprinkler. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff VV.

3. On 2-14-17 at 10:32 am, observation revealed within the nursing report room on the south end of the 2nd floor of the hospital, that an escutcheon ring was missing from a sprinkler head. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff VV.

4. On 2-14-17 at 10:34 am, observation revealed in the corridor outside of the elevator on the south end of the 2nd floor of the hospital near the nursing report room, that an escutcheon ring was missing from a sprinkler head. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff VV.

5. On 2-14-17 at 11:28 am, observation revealed in the storage room east of the elevator outside of Obstetrics, that an escutcheon ring around a sprinkler head was loose and was not tight to the ceiling. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff VV.

Based on observation and staff interview, the facility did not ensure that the corridor doors were maintained in accordance with NFPA 101 (2012 edition), 19.3.6.3. This condition could affect all 21 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

On 2-14-17 at 9:38 am, observation revealed that the double set of fire doors on the second level north of the atrium would not positively self-latch when tested and released three times. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff VV.

Based on observation and staff interview, the facility did not ensure that the fire resistance rating and smoke tightness of smoke barrier walls with sealed penetrations were maintained in accordance with NFPA 101 (2012 edition), 19.3.7.3 and 8.5. This condition could affect all 21 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

On 2-14-17 at 2:43 pm, observation revealed that the smoke barrier corridor wall of the electrical room, located near the main kitchen on the lower floor of the hospital, had two separate 1" penetrations that were not properly sealed in accordance with approved materials and methods. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff VV.

Based on observation and staff interview, the facility did not ensure that the smoke barrier doors were maintained in accordance with NFPA 101 (2012 edition), 19.3.7.8 and 8.5.4. This condition could affect all 21 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 2-14-17 at 9:54 am, observation revealed that the smoke barrier corridor double doors, located on the second level west of the cancer center entrance, had an approximate 1/2" gap at the intersection of the doors. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff VV.

2. On 2-14-17 at 10:15 am, observation revealed that the smoke barrier corridor double doors, located on the second level in the 1971 Hospital near the nurse station, would not fully close when operated three times. One leaf of the door was being held open by the coordinator. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff VV.

Based upon record review and staff interview, the facility did not ensure that quarterly fire drills were held at unexpected times once per each shift per quarter and under varying conditions in accordance with NFPA 101 (2012 edition),19.7.1.4 through 19.7.1.7. This condition could affect all 21 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

On 2-13-2017 at 2:25 pm, review of the facility fire drill report for the previous calendar year, revealed that no fire drill data was recorded for three of three shifts during quarter three (July, August, September) 2016. The condition was confirmed at the time of discovery by a concurrent record review and interview with Staff VV.

Based upon record review and staff interview, the facility did not ensure proper load testing of the surgery center emergency generator in accordance with NFPA 110 (2010 edition), 8.4.2. This condition could affect all 21 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

On 2-13-2017 at 3:15 pm, review of the surgery center generator testing reports for the previous calendar year revealed that during the monthly tests of the diesel generator, the facility was not operating the generator at a minimum 30% of the name plate kw rating. Further review of the report revealed that a load bank test was not performed in 2016 in lieu of meeting the 30% requirement. The condition was confirmed at the time of discovery by a concurrent record review and interview with Staff VV.