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Based on observation and interview, it was determined the facility failed to maintain building construction requirements in two locations, affecting one of five floors.

Findings include:

1. Observation on January 7, 2019, between 11:35 a.m. and 11:45 a.m., revealed the following:

a. 11:35 a.m., the external column, located closest to the fourth floor, common wall, with the adjacent health care building, required touch-up to spray fireproofing.
b. 11:45 a.m., construction plastic was located beyond the suspended ceiling assembly, within the fourth floor, Recreational Therapy.

Exit interview with facility representative one and facility representative two on January 8, 2019, between 9:15 a.m. and 9:30 a.m., confirmed the building construction deficiencies.

Based on observation and interview, it was determined the facility failed to maintain discharge from exits in two locations, affecting one of two floors.

Findings include:

1. Observation on January 14, 2019, between 9:50 a.m. and 10:00 a.m., revealed the following panic hardware was damaged:

a. 9:50 a.m., Maintenance exit.
b. 10:00 a.m., Loading Dock.

Exit interview with the facilities manager on January 14, 2019, between 11:15 a.m. and 11:30 a.m., confirmed the exit discharge deficiencies.

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of five floors.

Findings include:

1. Observation on January 7, 2019, at 12:27 p.m., revealed the third floor, Soiled Utility room door, lacked smoke-tight integrity.

Exit interview with facility representative one and facility representative two on January 8, 2019, between 9:15 a.m. and 9:30 a.m., confirmed the hazardous area enclosure deficiency.

Based on observation and interview, it was determined the facility failed to maintain two alcohol-based hand rub (ABHR) stations, affecting two of five floors.

Findings include:

1. Observation on January 7, 2019, between 11:47 a.m. and 12:20 p.m., revealed the following ABHR stations were positioned over trash receptacles.

a. 11:47 a.m., within the fourth floor, Recreational Therapy.
b. 12:20 p.m., within the third floor, Staff Lounge.

Exit interview with facility representative one and facility representative two on January 8, 2019, between 9:15 a.m. and 9:30 a.m., confirmed the ABHR station deficiencies.

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system, affecting four of four floors.

Findings include:

1. Observation on January 8, 2019, at 12:45 p.m., reveled the facility lacked documentation to support automatic sprinkler system maintenance and testing for the first and third quarters of calendar year 2018.

Exit interview with facility representative one on January 8, 2019, between 1:15 p.m. and 1:30 p.m., confirmed the facility lacked sprinkler system maintenance and testing data for the first and third quarters of calendar year 2018.

Based on observation and interview, it was determined the facility failed to maintain four corridor openings, affecting two of five floors.

Findings include:

1. Observation on January 7, 2019, between 12:25 p.m. and 1:20 p.m., revealed the following corridor doors lacked smoke-tight integrity:

a. 12:25 p.m., Patient room 314.
b. 1:10 p.m., Patient room 216.
c. 1:11 p.m., Patient room 212.
c. 1:20 p.m., Resident Laundry (second floor).

Exit interview with facility representative one and facility representative two on January 8, 2019, between 9:15 a.m. and 9:30 a.m., confirmed the corridor opening deficiencies.

Based on observation and interview, it was determined the facility failed to maintain one smoke barrier separation wall, affecting one of four floors.

Findings include:

1. Observation on January 8, 2019, at 11:15 a.m., revealed a penetration of the smoke barrier separation wall, within the fourth floor, Family Waiting room.

Exit interview with facility representative one on January 8, 2019, between 1:15 p.m. and 1:30 p.m., confirmed the smoke barrier separation wall deficiency.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier separation doors in two locations, affecting one of two floors.

Findings include:

1. Observation on January 14, 2019, between 10:33 a.m. and 10:45 a.m., revealed the following:

a. 10:33 a.m., the second floor, Pantry door (a single, smoke barrier separation door), was held open by unapproved means.
b. 10:45 a.m., a cart blocked the smoke barrier separation door, closest to second floor, Nourishment.

Exit interview with the facilities manager on January 14, 2019, between 11:15 a.m. and 11:30 a.m., confirmed the smoke barrier separation door deficiencies.

Based on documentation review and interview, it was determined the facility failed to conduct two of twelve required fire drills, affecting five of five floors.

Findings include:

1. Observation on January 8, 2019, at 8:23 a.m., revealed the facility lacked a third shift fire drill, for the second quarter of calendar year 2018, as well as a second shift fire drill, for the fourth quarter of 2018.

Exit interview with facility representative one on January 8, 2019, between 1:15 p.m. and 1:30 p.m., confirmed the facility lacked two of twelve required fire drills.