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Based on observation and interview, the facility failed to ensure the two hour barrier between the patient wing annex and business occupancy was free of penetrations. This has the potential to affect all patients and visitors to the facility. The census was 114 patients.

Findings include:

On 03/06/17 at 3:27 PM a tour was taken of the facility with Staff Q.

1.On 03/06/17 at 3:34 PM observation of the south side of the two hour fire barrier located above the double doors perpendicular to room (mechanical space) 149 revealed over the left leaf a three inch conduit open to air with multiple blue lines running through it.

On 03/06/17 at 3:34 PM in an interview, Staff Q confirmed the finding.

2. On 03/06/17 at 3:56 PM observation in the corridor and above the drop down ceiling of the two hour fire barrier located south and perpendicular to the double doors perpendicular to room 1276 revealed an annular space around a one inch conduit.

On 03/06/17 at 3:56 PM in an interview, Staff Q confirmed the finding.

3. On 03/06/17 at 4:15 PM observation of the door to room 141 revealed it was in a two hour fire barrier. Observation of the door revealed its glass window (two foot by two foot in size) was not rated. The observation revealed it had a self-closer, but that closer was unable to self-close the door because it was propped open by a chair with no staff in the area.

On 03/06/17 at 4:15 PM in an interview, Staff Q confirmed the finding.

4. On 03/06/17 at 4:17 PM observation above the drop down ceiling of the two hour barrier as seen above the left side of the door (as seen within the room) revealed a metal sleeve with an annular space.

On 03/06/17 at 4:17 PM in an interview, Staff Q confirmed the finding.

5. On 03/06/17 at 4:24 PM observation above the drop down ceiling of the two hour barrier as seen above room 141 door as seen from the corridor revealed a stainless steel conduit with an annular space and corrugated decking perpendicular to the barrier. Observation of the corrugations revealed they were loosely filled with insulation, allowing for the passage of smoke and particles of combustion.

On 03/06/17 at 4:24 PM in an interview, Staff Q confirmed the finding.

6. On 03/06/17 at 4:35 PM observation above the drop down ceiling of the two hour barrier as seen from the north side of the double doors perpendicular to room (office) 131 revealed over the right door one blue line with an annular space around it.

On 03/06/17 at 4:35 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each hazardous area had self-closing doors and the stated protection rating of the barriers to said areas were maintained. This has the potential to affect all patients and visitors to the facility. The census was 114 patients.

Findings include:

On 03/07/17 at 2:30 PM a tour was taken of the facility with Staff R.

1. On 03/07/17 at 3:23 PM observation of the one hour barrier surrounding the room 227, the laundry room, revealed a gap between the barrier and the deck.

On 03/07/17 at 3:23 PM in an interview, Staff R confirmed the finding.

2. On 03/07/17 at 4:12 PM observation of the 400 unit laundry room revealed it had one hour protection for 90 degrees, and two hour protection barrier on the opposite 90 degrees. Observation of the door revealed it was not on a self-closer. Observation above the drop down ceiling revealed gaps between the barrier and deck.

On 03/07/17 at 4:12 PM in an interview, Staff R confirmed the finding.


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3. During the tour of the facility on 03/08/17, above the drop down ceiling in the laundry room of the 300 Unit, it was noted that a 4 inch sprinkler pipe and a 1 1/2 " sprinkler pipe passed thru the fire walls and was not sealed around the pipes with fire stop material. The fire wall also failed to be sealed to the upper deck around the room.

Staff CC confirmed this at the time of discovery.

Based on document review and interview, the facility failed to ensure all pull stations and fire alarm visual signal devices were tested annually. This has the potential to affect all patients and visitors to the facility. The census was 114 patients.

Findings include:

On 03/08/17 at 3:05 PM a second tour of the facility was taken with Staff Q and R.

On 03/08/17 at 3:05 PM two pull stations were observed at the annex 100 wing nurse's station location.

On 03/08/17 at 3:05 PM visual only fire alarm visual signal devices were observed outside patient rooms 310, 311, 312, 313, 314, and 315.

On 03/08/17 at 3:14 PM visual only fire alarm signal devices were observed outside patient rooms 410, 411, 412, 413, 414, and 416.

On 03/08/17 a review of the facility's life safety code documentation was completed. The review revealed the latest fire alarm test was done 02/01/17. Review of that test did not reveal where the aforementioned fire alarm signal devices had been tested, and it revealed only one pull station had been tested in the annex 100 wing nurses station.

On 03/08/17 at 3:14 PM in an interview, Staff Q confirmed the finding.

Based on observation and staff interview it was determined that the facility failed to maintain the sprinkler heads to be free of foreign material as outlined in NFPA 101 2012 Edition, Chapter 9.7.5 therefore NFPA 25 2011 Edition, Chapter 5.2.1.1.1 This has a potential to affect all patients and visitors to the facility. Census at the time of survey was 114.

Findings:

During the tour of the facility on 03/06/17 at 3:20 PM it was noted that multiple sprinkler heads third and second floor of the main building had significant amounts of foreign material buildup on the sprinkler heads. During the tour of the first floor of the main building on 03/07/17 it was also noted the multiple sprinkler heads had significant amounts of foreign material buildup on them. Staff Q and BB confirmed the findings at the time of discovery.

Based on observation and staff interview it was determined that the facility failed to maintain the sprinkler heads to be free of foreign material as outlined in NFPA 101 2012 Edition, Chapter 9.7.5 therefore NFPA 25 2011 Edition, Chapter 5.2.1.1.1 This has a potential to affect all patients and visitors to the facility. Census at the time of survey was 114.

Findings:

During the tour of the facility on 03/06/17 at 3:20 PM it was noted that multiple sprinkler heads within the 500 unit, located in the B wing, on the second floor of the main building, were noted to have foreign material buildup on them.

Staff BB confirmed the findings at the time of discovery.

Based on observation and interview, the facility failed to maintain the stated rating of its smoke and fire barriers. This has the potential to affect all patients and visitors to the facility. The census was 114 patients.

Findings include:

On 03/07/17 at 2:30 PM a tour was taken of the facility with Staff R.

1. On 03/07/17 at 2:35 PM observation of the two hour fire barrier as seen from within room 218 revealed over each bed a one inch by eight inch penetration within the barrier and within the penetration there was a flex conduit.

The observation also revealed a corrugated deck perpendicular to the barrier, with the corrugations filled with loose insulation.

On 03/07/17 at 2:35 PM in an interview, Staff R confirmed the finding.

2. On 03/07/17 at 3:03 PM observation above the drop down ceiling of the one hour fire barrier over room 202, as seen from within 202, revealed to the left of the door space above a heating, ventilation, and cooling duct and loose rockwool in corrugated spacing between the barrier and the corrugated deck.

On 03/07/17 at 3:03 PM in an interview, Staff R confirmed the finding.

3. On 03/07/17 at 3:05 PM observation above the drop down ceiling of the one hour fire barrier on the west side of room 202 revealed an annular space around a one inch corrugated conduit.

On 03/07/17 at 3:05 PM in an interview, Staff R confirmed the finding.

4. On 03/07/17 at 3:08 PM observation above the drop down ceiling of the one hour barrier to the left of door (seen from within) revealed an orange conduit that when traced to the closet had an open end.

On 03/07/17 at 3:08 PM in an interview, Staff R confirmed the finding.

5. On 03/07/17 at 3:38 PM observation above the drop down ceiling of the two hour barrier perpendicular to and just north of the 400 unit and between the units and the common corridor, revealed gaps in the corrugations of the ceiling and the barrier.

On 03/07/17 at 3:38 PM Staff R confirmed the finding.

6. On 03/07/17 at 4:04 PM observation above the drop down ceiling of the one hour barrier in room 435 revealed gaps between the deck and the barrier.

On 03/07/17 at 4:04 PM in an interview, Staff R confirmed the finding.

7. On 03/07/17 at 4:12 PM observation of the 400 unit ice machine room, (room 407), revealed it was surrounded by one hour protective construction. Observation above the drop down ceiling of the room revealed between the corrugated deck and the barrier there was loose insulation in the corrugations. Observation of the barrier over the ice machine revealed an annular space around a corrugated conduit.

On 03/07/17 at 4:12 PM in an interview, Staff R confirmed the finding.

8. On 03/07/17 at 4:15 PM observation of storage room 401 revealed it was surround by one hour protective construction. The observation revealed the barrier was perpendicular to a corrugated deck that had loose insulation in the corrugations.

On 03/07/17 at 4:15 PM in an interview, Staff R confirmed the finding.

Based on observation and interview, the facility failed to ensure each door in a smoke barrier self-closed. This has the potential to affect all patients and visitors to the facility. The census was 114 patients.

Findings include:

On 03/07/17 at 2:30 PM a tour was taken of the facility with Staff R.

1. On 03/07/17 at 3:11 PM observation of the ice room (room 208) revealed it was surrounded by a one hour protective construction. Observation of the door to the room revealed it was not on a self-closer.

On 03/07/17 at 3:11 PM in an interview, Staff R confirmed the findings.

2. On 03/07/17 at 4:15 PM observation of the 400 unit ice machine room, (room 407), revealed it was surrounded by one hour protective construction. Observation of the door revealed it was not on a self-closer.

On 03/07/17 at 4:15 PM in an interview, Staff R confirmed the finding.

3. On 03/09/17 at 11:18 AM, the double doors in the fire barrier on the 400 unit were observed to be held open. When tested, the fire alarm system released the doors, but one leaf did not close.

On 03/09/17 at 11:18 AM in an interview, Staff Q confirmed the finding.

Based on observation, document review, and interview the facility failed to inspect the function of the fire dampers within the air conditioning system in accordance with Chapter 9.2 of NFPA 101, 2012 edition and therefore 5.4.8 of NFPA 90A 2012 edition and therefore 19.4.1.1 in NFPA 80. This has the potential to affect all patients and visitors to the facility. The facility census at the time of survey was 114.

Findings:

During the tour of the facility it was noted that above the drop down ceiling there were fire dampers installed at the fire walls in the main building. During review of the fire damper inspection report dated 11/2016 it was noted that 19 fire dampers were Non-Accessible. The inspection report revealed the location of three of these dampers were in the B tower that housed the 500 unit for the hospital in-patients on the second floor. The inspection report revealed that these three dampers were not inspected or tested at the time, as they were inaccessible. During interview with Staff Q and BB on 03/08/17 at 4:30 PM it was revealed that the facility had not made these accessible nor reinspection completed.

Based on document review and interview, the facility failed to ensure its fire drills included transmission of a fire signal. This has the potential to affect all patients and visitors to the facility. The census was 114 patients.

Findings include:

On 03/08/17 a review of the facility's fire plan was completed. The review did not include an emergency phone call to the fire department.

On 03/08/17 at 4:30 PM in an interview, Staff Q confirmed the finding.

Based on document review and interview, the facility failed to ensure its fire drills included transmission of a fire signal. This has the potential to affect all patients and visitors to the facility. The census was 114 patients.

Findings include:

On 03/08/17 a review of the facility's fire drills was completed. The review did not reveal where night shift drills included the transmission of a fire alarm signal.

On 03/08/17 at 9:45 AM in an interview, Staff R confirmed there was no transmission of the fire alarm signal during the night shift drills.

Based on interview and record review, the facility failed to determine by a formal and documented risk assessment procedure what risk category each of its building systems were in accordance with NFPA 99, 2012 edition, chapter 4. This has the potential to affect all patients and visitors. The census was 114 patients.

Findings include:

A review of documentation of the facility's building systems was completed on 03/09/17. The review did not include the risk category to which each system was assigned.

On 03/09/17 at 10:50 AM in an interview, Staff Q stated a risk assessment of each of the building's systems has not yet been completed.