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Based on observation and interview, the provider failed to maintain the fire-resistive design for one of one horizontal exit and building separation wall (between the hospital and the clinic). Findings include:

1. Observation on 3/2/22 at 1:15 p.m. revealed the two-hour, fire-rated separation wall between the hospital and the clinic had a brick removed above the ceiling. The brick had been removed as a pathway for the low voltage cables which partially filled the hole. No attempt was made to provide a fire seal.

Interview on 3/2/22 at 1:20 p.m. with the maintenance supervisor confirmed that condition. He verified a variety of fireproofing alternatives could be used to seal the penetration.

The deficiency could affect 100% of the occupants of the smoke compartment.

Based on record review and interview, the provider failed to continuously maintain automatic sprinklers in reliable operating condition (quarterly flow testing not performed). Findings include:

1. Record review on 3/2/22 at 2:30 p.m. revealed the required quarterly flow tests had not been performed in the past three years.

Interview with the maintenance supervisor at the time of the record review confirmed that condition.

Failure to continuously maintain the automatic sprinkler system as required increases the risk of death or injury due to fire.

The deficiency affected one of the numerous required tests on the automatic sprinkler system.

Based on record review and interview, the facility failed to conduct fire drills as required (fire drills not conducted at varied times and transmission of alarm not verified). Findings include:

1. Record review on 3/2/22 at 2:20 p.m. revealed fire drills were not conducted at varied times in the past year as noted below. Fire drills are required to be conducted quarterly on each shift under varied conditions. Time of day is one of the conditions that must be varied.

*Day shift drills conducted at 3:00 p.m., 8:15 a.m., 8:30 a.m., 8:25 a.m., 8:40 a.m., 8:55 a.m. in the past year.
*Night shift drills conducted at 11:20 p.m., 8:30 p.m., 11:25 p.m., 10:45 p.m., 10:15 p.m., 9:15 p.m. in the past year.

2. Record review on 3/2/22 at 2:20 p.m. revealed fire drill documentation did not include verification of alarm transmission.

Interview of 3/2/22 at 2:45 with the director of maintenance confirmed the drill times and the lack of verification of signal transmission.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiencies affected two of two shifts.

Based on observation and interview, the facility failed to provide a maintenance plan for piped medical gases as required.

Findings include:

1. Record review on 3/2/22 at 1:30 p.m. revealed a plan to provide a medical gas outlet and system maintenance was not available. Interview with the maintenance director and associates in respiratory therapy, nursing, and administration during the facility tour on 3/2/22 revealed no planning for maintenance or repair was available.

The deficiency could impact any patients within the hospital.

Based on record review and interview, the provider failed to perform generator maintenance as required. The automated system provided required loaded and unloaded testing, but the documentation was not provided. Findings include:

1. Record review on 3/2/22 at 3:10 p.m. revealed documentation of diesel generator load runs were for thirty minutes (0.5 hours) each month only included the date of the run and whether it was run with a load transfer to the generator or not.

Interview with the maintenance supervisor at the time of the record review confirmed that finding. Further interview with the maintenance supervisor revealed he was unaware of the necessity of determining whether the load met or exceeded thirty percent of the diesel generator nameplate capacity. No-load calculation had been performed in the past three years. While the diesel generator has annual maintenance performed, no documentation was provided, and the no-load bank had been performed.

The deficiency affected one of numerous generator maintenance requirements.