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Based on observation, testing, and interview the provider failed to maintain the fire-resistive characteristics of the two-hour fire-rated wall between the hospital and the ambulance garage in one of one location (door into the ambulance garage). Findings include:
1. Observation at 2:15 p.m. on 11/18/14 revealed an ambulance garage (a storage occupancy) in the emergency room (ER) department (a healthcare occupancy). Observation revealed a two-hour fire-rated wall separating the garage from the healthcare occupancy. The door to that ambulance garage was a listed 90 minute fire-rated door and was equipped with a self-latching hardware. The hardware was fire-rated and provided with points of latching at the top and bottom of the door. Testing of that door revealed the positive latching hardware was not catching at either of the top or bottom latching points. The door was able to be pushed open without the use of the push bar latch release mechanism. Interview with the maintenance supervisor at the time of observation confirmed that condition. He indicated that door latching hardware was working properly when last checked.

Based on observation, testing, and interview, the provider failed to maintain the door to an exit passageway in one randomly observed location (exit passageway for basement stairwell and operating room [OR] suite). Findings include:

1. Observation at 3:40 p.m. on 11/18/14 revealed an exit passageway serving as a means of egress from the basement stairwell and OR suite. Further observation revealed the door was equipped with a self-closing device. Testing of that door and self-closing device revealed it would not close and latch into its frame. The self-closing device was out of adjustment and was unable to fully close the door allowing the positive latching hardware to latch into the door frame. Interview with the maintenance supervisor at the time of observation confirmed that condition. He indicated that door was working properly when it was last checked.

Based on observation and interview, the provider failed to ensure the facility was protected throughout by automatic sprinklers in one randomly observed location (dishwash room). Findings include:

1. Observation at 10:50 a.m. on 11/18/14 revealed a dishwash room in the dietary area was not provided with sprinkler protection. All rooms in a complete automatic fully sprinkled NFPA 13 facility shall be provided with sprinkler protection. Interview with the maintenance supervisor at the time of the observation revealed he was unaware that room had not been provided with sprinkler protection.

Based on observation and interview, the provider failed to conduct the required biannual inspection of the cooking facility's fire suppression system in one of one location (kitchen). Findings include:

1. Observation at 11:10 a.m. on 11/18/14 revealed a commercial kitchen hood in the dietary department. Further observation revealed that commercial kitchen hood was equipped with an Amerax KP-275 wet chemical fire suppression system. The KP-275 wet chemical system was tagged with an inspection tag dated March 2014. That system is required to be inspected every six months in accordance with NFPA 96. Eight months had lapsed since the last inspection.

Interview with the maintenance supervisor at the time of the observation confirmed that condition. He further indicated the dietary supervisor was in charge of ensuring that system was inspected and maintained on a regular basis. The dietary manager was unavailable for interview at the time of the survey. No documentation of the last inspection dated March 2014 was available for review at the time of survey.

Based on observation and interview, the provider failed to maintain means of egress free from obstructions in one randomly observed location (exit passageway for operating room [OR] suite and basement stairwell). Findings include:

1. Observation at 11:45 a.m. on 11/18/14 revealed an enclosed exit passageway serving as a means of egress for the OR suite and basement stairwell that lead outside. Further observation revealed that exit passageway was being used for storage of miscellaneous construction materials. Those construction materials would impede use of that means of egress in the event of a fire or other emergency. Interview with the maintenance supervisor at the time of observation confirmed that condition. He indicated the materials were temporarily being stored there during construction.

Based on observation and interview, the provider failed to install a remote stop button for one of one emergency power supply system. Findings include:

1. Observation at 10:30 a.m. on 11/18/14 revealed a room housing the essential electrical system (EES) and Level 1 type 10 Class X emergency power supply system (EPSS). The level 1 EPSS shall be provided with a remote manual stop station located outside the room housing the prime mover. Interview with the maintenance supervisor at the time of the observation revealed he was unaware of the remote manual stop requirement for the EPSS.

Based on observation, testing and interview, the provider failed to maintain electrical wiring and equipment in operating condition in one randomly observed location (generator room). Findings include:

1. Observation at 10:45 p.m. on 11/18/14 revealed the life safety branch electric panel of the type 1 essential electric system (ESS) in the generator room. Observation revealed one of the circuits breakers (circuit 8) on that panel was tripped. The maintenance supervisor at the time of the observation tested the equipment by trying to reset that breaker to circuit 8. In doing so another circuit breaker tripped (circuit 4). Interview with maintenance supervisor at the time of the observation and testing revealed he was not exactly sure which circuits those supplied. The panel circuit list indicated they supplied exit egress lighting in the north wing. He indicated he would have an electrician look at why they were tripping.

Based on observation, testing, and interview the provider failed to maintain the fire-resistive characteristics of the two-hour fire-rated wall between the hospital and the ambulance garage in one of one location (door into the ambulance garage). Findings include:
1. Observation at 2:15 p.m. on 11/18/14 revealed an ambulance garage (a storage occupancy) in the emergency room (ER) department (a healthcare occupancy). Observation revealed a two-hour fire-rated wall separating the garage from the healthcare occupancy. The door to that ambulance garage was a listed 90 minute fire-rated door and was equipped with a self-latching hardware. The hardware was fire-rated and provided with points of latching at the top and bottom of the door. Testing of that door revealed the positive latching hardware was not catching at either of the top or bottom latching points. The door was able to be pushed open without the use of the push bar latch release mechanism. Interview with the maintenance supervisor at the time of observation confirmed that condition. He indicated that door latching hardware was working properly when last checked.

Based on observation, testing, and interview, the provider failed to maintain the fire-resistive characteristics of the two hour fire-resistive wall between the hospital and the clinic in one randomly observed location (laboratory [lab] room). Findings include:

1. Observation at 2:45 p.m. on 11/18/14 revealed a lab suite in the clinic of building 03, a business occupancy. Further observation revealed a two-hour fire rated wall separating building 01 from building 03 on the north wall of that lab suite. A door in that wall provided access from the lab to the lab storage and lab office. That door was a listed 90 minute fire-rated door and equipped with a magnetic hold open device and door closer. Testing of that door upon release of the magnetic hold open device revealed that door was unable to close as storage in front of it would impede the swing. Removal of that storage allowed the door to close properly and latch into the door frame. Interview with the maintenance supervisor at the time observation confirmed that condition. He indicated that door was periodically checked as part of the provider ' s preventative maintenance plan. He also indicated that storage in front of this door has been an issue in the past.

Based on observation, testing, and interview, the provider failed to maintain the door to an exit passageway in one randomly observed location (exit passageway for basement stairwell and operating room [OR] suite). Findings include:

1. Observation at 3:40 p.m. on 11/18/14 revealed an exit passageway serving as a means of egress from the basement stairwell and OR suite. Further observation revealed the door was equipped with a self-closing device. Testing of that door and self-closing device revealed it would not close and latch into its frame. The self-closing device was out of adjustment and was unable to fully close the door allowing the positive latching hardware to latch into the door frame. Interview with the maintenance supervisor at the time of observation confirmed that condition. He indicated that door was working properly when it was last checked.

Based on observation, testing, and interview, the provider failed to maintain 90 minute horizontal exit doors in operating condition in one randomly observed location (cross-corridor doors between building 01 and building 02 near the chapel). Findings include:

1. Observation at 12:15 p.m. on 11/18/14 revealed cross-corridor horizontal exit doors separating building 01 (original building) and building 02 (1999 addition) near the chapel. The 90 minute fire-rated doors were equipped with a magnetic locking device tied to a badge reader. The magnetic device would lock one of the door leafs during non-business hours to secure entry from building 02 into 01. The opposite leaf was not equipped with a locking feature for entry from building 01 into 02. The magnetic lock was not provided with a delayed egress feature as required in a means of egress. The positive latching hardware installed on that door had been modified, so it would not latch into the door frame.

Interview with the maintenance supervisor at the time of the observation revealed that hardware had been modified, so the automatic door opener would work properly. He indicted the door opener was installed for movement of patients through those doors. He indicated he was unaware of the latching requirement for that door.

Based on observation and interview, the provider failed to ensure responding staff were familiar with fire drill procedures. Findings include:

1. Observation at 4:00 p.m. on 11/18/14 during a fire drill revealed the staff responding to the fire drill did not follow the R.A.C.E (Rescue, Alarm, Contain, Extinguish) procedure adopted by the provider. Upon finding the simulated fire in patient room 215 a responding nurse communicated a code red to the other responding nurses. She then entered the room and relocated the patient to the corridor. She failed to close the door to that room to contain the smoke and fire. She also failed to relocate that patient to a different smoke compartment or room.

A code red was called over the paging system and numerous staff responded with and without fire extinguishers to the simulated fire origin in room 215. The fire alarm signaling system was not activated until the maintenance supervisor quizzed the staff what they were forgetting. The fire alarm was then activated by means of a manual pull station. Nurses continued to close corridor doors to contain smoke and fire. The fire was simulated as being extinguished and an all clear was called.

Interview with the maintenance supervisor after the fire drill was conducted revealed he confirmed the issues. He indicated staff may not have been familiar with the way this fire drill was conducted. He indicated the fire alarm was usually activated to simulate a fire situation in most drills to see how staff responded to finding where the fire was located.

Based on observation and interview, the provider failed to ensure the facility was protected throughout by automatic sprinklers in one randomly observed location (dishwash room). Findings include:

1. Observation at 10:50 a.m. on 11/18/14 revealed a dishwash room in the dietary area was not provided with sprinkler protection. All rooms in a complete automatic fully sprinkled NFPA 13 facility shall be provided with sprinkler protection. Interview with the maintenance supervisor at the time of the observation revealed he was unaware that room had not been provided with sprinkler protection.

Based on record review and interview, the provider failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition and inspected and tested periodically in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Findings include:

1. Review of the provider's automatic sprinkler system inspection reports at 9:00 a.m. on 11/18/14 revealed missing documentation for required testing and maintenance that was to be conducted. A five year internal obstruction investigation should have been conducted. No documentation was provided indicating a five year internal obstruction investigation had ever been done. Quarterly flow testing should have been conducted. No documentation indicated either of those testing and maintenance procedures was available.

Interview with the plant operations supervisor at the time of the record review confirmed that condition. He indicated he was unware of the five year internal obstruction investigation requirement. He also indicated the provider had just signed a contract with Building Sprinkler Inc. to start doing the quarterly flow testing.

Based on observation and interview, the provider failed to conduct the required biannual inspection of the cooking facility's fire suppression system in one of one location (kitchen). Findings include:

1. Observation at 11:10 a.m. on 11/18/14 revealed a commercial kitchen hood in the dietary department. Further observation revealed that commercial kitchen hood was equipped with an Amerax KP-275 wet chemical fire suppression system. The KP-275 wet chemical system was tagged with an inspection tag dated March 2014. That system is required to be inspected every six months in accordance with NFPA 96. Eight months had lapsed since the last inspection.

Interview with the maintenance supervisor at the time of the observation confirmed that condition. He further indicated the dietary supervisor was in charge of ensuring that system was inspected and maintained on a regular basis. The dietary manager was unavailable for interview at the time of the survey. No documentation of the last inspection dated March 2014 was available for review at the time of survey.

Based on observation and interview, the provider failed to maintain means of egress free from obstructions in one randomly observed location (exit passageway for operating room [OR] suite and basement stairwell). Findings include:

1. Observation at 11:45 a.m. on 11/18/14 revealed an enclosed exit passageway serving as a means of egress for the OR suite and basement stairwell that lead outside. Further observation revealed that exit passageway was being used for storage of miscellaneous construction materials. Those construction materials would impede use of that means of egress in the event of a fire or other emergency. Interview with the maintenance supervisor at the time of observation confirmed that condition. He indicated the materials were temporarily being stored there during construction.

Based on observation and interview, the provider failed to install a remote stop button for one of one emergency power supply system. Findings include:

1. Observation at 10:30 a.m. on 11/18/14 revealed a room housing the essential electrical system (EES) and Level 1 type 10 Class X emergency power supply system (EPSS). The level 1 EPSS shall be provided with a remote manual stop station located outside the room housing the prime mover. Interview with the maintenance supervisor at the time of the observation revealed he was unaware of the remote manual stop requirement for the EPSS.

Based on observation, testing and interview, the provider failed to maintain electrical wiring and equipment in operating condition in one randomly observed location (generator room). Findings include:

1. Observation at 10:45 p.m. on 11/18/14 revealed the life safety branch electric panel of the type 1 essential electric system (ESS) in the generator room. Observation revealed one of the circuits breakers (circuit 8) on that panel was tripped. The maintenance supervisor at the time of the observation tested the equipment by trying to reset that breaker to circuit 8. In doing so another circuit breaker tripped (circuit 4). Interview with maintenance supervisor at the time of the observation and testing revealed he was not exactly sure which circuits those supplied. The panel circuit list indicated they supplied exit egress lighting in the north wing. He indicated he would have an electrician look at why they were tripping.