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Based on observation and interview, the facility failed to assure construction was separated from occupied areas. These deficient practices would allow smoke, fire and gasses to spread throughout the exit corridors. The facility has the capacity for 77 beds with a census of 23 on the day of survey.

Findings are:
Observation on 12-18-23 at 1:15 pm revealed:
1. No fire rated separation between the occupied health care area and areas under construction, non-rated, non-latching double doors and a glass door were installed.

During an interview on 12-18-23 at 1:15 pm, Staff A confirmed the lack of separation between the construction area and occupied areas.

Based on observation and interview, the facility failed to maintain a 2-hour fire separation. This deficient practice would allow smoke, fire and gases to migrate from the Hospital into the Business occupancy link. The facility has the capacity for 77 beds with a census of 23 on the day of survey.

Findings are:
Observation on 12-8-23 between 2:09 pm and 2:19 pm revealed:
1. The south 1 ½ -hour fire rated double doors next to room S40 failed to latch within the doorframe.
2. 2A103 1 ½ -hour fire rated double doors failed to latch within the doorframe.
3. 2A103 1 ½ -hour fire rated north door failed to latch within the doorframe.

During an interview on 12-8-23 between 2:09 pm and 2:19 pm, Staff A confirmed the 1 ½ hour fire rated doors failed to latch within the doorframe.

Based on observation and interview, the facility failed to maintain means of egress free of obstructions. This deficient practice would delay egress and not impede it to full instant use in the case of fire or other emergencies. The facility has the capacity for 77 beds with a census of 23 on the day of survey.

Findings are:
Observations on 12-18-23 at 1:28 pm revealed, numerous construction barriers obstructing the corridors.

During interview on 12-18-23 at 1:28 pm, Staff A confirmed the barriers in the corridor.

Based on observation and staff interview, the facility failed to provide self-closing devices and failed to assure enclosures for hazardous areas to separate them from the rest of the facility. This deficient practice would allow fire, smoke and gases to migrate into the exit corridors. The facility has the capacity for 77 beds with a census of 23 on the day of survey.

Finding are:
Observation on 12-18-23 between 1:31 pm and 2:20 pm, revealed the following:
1. 2C108 room door failed to provide a self-closing device.
2. 2277 clean supply room door equipped with a self-closing device failed to latch within the doorframe.
3. 2B123 door equipped with a self-closing device had tape covering the latch, the door failed latch within the doorframe.
4. 2B125 IT room door failed to provide a self-closing device.
5. 2321 employee only door equipped with self-closing device failed to latch within doorframe.
6. 2A135 equipment storage room over 100 square feet, failed to provide a self-closing device.
7. 2A137 storage room door equipped with a self-closing device, failed to latch within the doorframe.

During interview on 12-18-23 between 1:31 pm and 2:20 pm, Staff A confirmed the findings.

Based on observation and interview, the facility failed to assure that tiles were placed in the ceiling grid within hazardous areas. This deficient practice would not allow the fire sprinkler system to operate as designed. The facility has the capacity for 77 beds with a census of 23 on the day of survey.

Findings are:
Observations on 12-18-23 at 1:51 pm and 1:54 pm revealed:
1. Room 2272 open ceiling tile.
2. Room 2275 two open ceiling tiles.

During an interview on 12-18-23 at 1:51 pm and 1:54 pm, Staff A confirmed the missing ceiling tiles.

Based on observation and interview, the facility failed to assure doors to the corridor would latch. This deficient practice would allow smoke, fire and gasses to enter the exit corridor. The facility has the capacity for 77 beds with a census of 23 on the day of survey.

Findings are:
Observations on 12-18-23 at 1:49 pm revealed, 2C103 door equipped with a small leaf failed to auto latch within the doorframe.

During an interview on 12-18-23 at 1:49 pm, Staff A confirmed the doors failed to latch within the doorframe when closed.

Based on observation and interview the facility failed to assure that the fire-rated door to the soiled linen/trash would latch within the doorframe. This deficient practice had the potential to spread smoke, gasses and fire outside the room into the corridor. The facility has the capacity for 77 beds with a census of 23 on the day of survey.

Findings are:
Observations on 12-18-23 at 2:14 pm revealed:
1. The fire rated door to the soiled linen chute failed to latch within the frame.
2. The fire rated door to the rubbish chute failed to latch within the frame.

During an interview on 12-18-23 at 2:14 pm, Staff A confirmed the chute doors failed to latch within the frame.

NFPA Standard:
NFPA 82, 1999, 3-2.2.9
Gravity chutes shall be constructed so that the base opening of the chute or shaft, or both, shall be protected by an approved automatic-closing or self-closing 1-hour fire door suitable for a Class B opening.

Based on observation and interview, the facility failed to conduct electrical receptacle testing for newly installed hospital grade outlets. These deficient practices would create electrical injury and fire hazards. The facility has the capacity for 77 beds with a census of 23 on the day of survey.

Findings are:
Observations on 12-18-23 between 1:30 pm and 2:30 pm revealed, newly installed hospital grade outlets throughout the facility.

During an interview 12-18-23 between 1:30 pm and 2:30 pm, Staff A confirmed the lack of testing of newly installed hospital grade outlets.

NFPA Standard:
NFPA 99, 2012, 6.3.4.1.1
Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.

2012 NFPA 99
6.3.3.2.1
The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2
The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3
Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4

Based on observation and interview, the facility failed to assure that electrical adaptors were not in use.
This deficient practice would increase the potential for an electrical fire. The facility has the capacity for 77 beds with a census of 23 on the day of survey.

Findings are:
Observations on 12-18-23 at 1:46 pm revealed, an electrical adaptor plugged into a floor fan in Therapy room 2C105.

During an interview on 12-18-23 at 1:46 pm, Staff A confirmed the use of electrical adaptor.