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Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining self closing smoke barrier doors as required. The failure to maintain these doors as required has the potential to cause harm to 10% of the staff and residents.

The findings include:

During the validation survey on December 13, 2017 at approximately 1210 hours it was observed and confirmed through interview with the Director of Safety that the automatic closing cross-corridor smoke barrier door at the Family Waiting Room on 6 East (door assembly #077567) was obstructed from closing as required due to the door catching on the floor in the door opening.

All doors in smoke barrier door assemblies must be self-closing and/or automatic closing in the event of an emergency and must not be held open unless by an approved device that is released by the fire alarm systems. This has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based on observation of the physical environment, review of the facility's records, and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining all water based suppression systems as required by NFPA 25. This failure to maintain all water based suppression systems as required has the potential to cause harm to 100% of the staff and residents

The findings include:

During the validation survey on December 13, 2017 at 1015 hours it was determined through a review of the facility's records and confirmed through interview with the Director of Safety that the standpipe systems throughout the facility were not documented as being inspected and tested as required. No records of the required annual inspection and test of the standpipe systems, hydrostatic tests, and a 5 year flow test of the standpipe systems was available for review at the time of the survey.

During the validation survey on December 13, 2017 at 1025 hours it was determined through a review of the facility's records and confirmed through interview with the Director of Safety that the private fire hydrants and mains throughout the facility campus were not documented as being inspected and tested as required. No record of the required 5 year flow test for the private fire hydrants and mains was available for review at the time of the survey.

During the validation survey on December 13, 2017 at 1030 hours it was determined through a review of the facility's records and confirmed through interview with the Director of Safety that the water storage tanks for the fire suppression systems of the facility were not documented as being inspected and tested as required. No records of the required inspections and tests were available at the time of the survey.

The failure to maintain the water based suppression systems as required by NFPA 25 and document the inspection, test, and maintenance of these systems as required could lead to improper operation of the systems in the event of an emergency thereby promoting harm to occupants of the facility.