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Based on observation during facility tour and staff interview it was determined the facility failed to ensure the sprinkler system was properly maintained according to the National Fire Protection Association (NFPA) 25. This had the potential to affect all those utilizing these areas of the facility. The census at the beginning of the survey was 45.

Findings include:

Facility tour took place on 04/04/17 at 11:15 AM with the maintenance supervisor. During tour of the first floor area, specifically within the dry storage room of the kitchen, observation was made of two sprinkler head pendants having dust and debris coating the glass globe of the sprinkler head.

Tour of the second floor area, specifically the nurse station in the ICU revealed one sprinkler head pendant having dust and debris coating the glass globe of the sprinkler head. Other dirty sprinkler heads were observed at the E pod nurse station, the physician's dictation room (2055) and the nurse station adjacent to and bordering the physician's dictation room.

The maintenance supervisor verified these findings at the time of this observation.

Based on observation during facility tour and staff interview it was determined the facility failed to ensure the integrity of the smoke rated barrier according to the National Fire Protection Association 101, 2012 edition, Chapter 19. This had the potential to affect all those utilizing these areas of the facility. The census at the beginning of the survey was 45.

Findings include:

Facility tour took place on 04/04/17 at 11:15 AM with the maintenance supervisor. During tour of the smoke barrier observation was made of penetrations in the following areas above the ceiling tiles:

First floor:
1. Two unsealed flex conduits around the annular space above the double smoke barrier doors located between the materials management and the mechanical room.

2. One open end conduit within the corridor of the back (south) wall of the therapy room just to the right of the Kindred Hospital award board.

3. Two open end conduits within the smoke barrier wall located in the corridor separating the therapy department and the cafe and at the east end of the "zig zag" area of the wall.

The maintenance supervisor verified these findings at the time of this observation.

Based on observation during facility tour and staff interview it was determined the facility failed to ensure all doors in the smoke barrier met the requirements of the National Fire Protection Association (NFPA) 101, 2012 edition, chapter 19. This had the potential to affect all those utilizing these areas of the facility. The census at the beginning of the survey was 45.

Findings include:

Facility tour took place on 4/4/17 at 11:15 AM with the maintenance supervisor. During tour of the first floor smoke barrier, observation was made of the door to room 1142 (director of marketing) lacking a self-closing or automatic closing device. Additionally, during tour of the second floor smoke barrier, specifically office room 2078, observation was made of the smoke barrier door propped open with a rubber wedge placed at the bottom of the door which disabled the self -closing device.

The maintenance supervisor verified this finding at the time of this observation.