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The facility failed to ensure corridor doors were equipped with automatic latching hardware suitable for keeping the door closed and resistant to the passage of smoke.

Observation determined the corridor door to the E.R.Room did not latch into the door frame.

The facility failed to ensure walls that enclose hazardous areas would resist the passage of smoke.

Observation determined the northeast corner of the Boiler Room had unsealed spaces around electrical conduit penetrating through the wall.

Keyed locks, dead bolt locks and multi-latching devices create an impediment to egress from habitable spaces. Doors shall be operable with not more than one releasing operation. 7.2.1.5.4

The facility failed to ensure exit access was readily accessible at all times.

Observation determined the sliding door in the path of egress near the Ambulance Office had a deadbolt lock.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

Observation determined the stairway next to the freight elevator did not have sprinkler coverage on the landing area between the basement and first floor.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Observation determined:
1) The sprinkler in the I.T. Room of the Clinic was obstructed by data cables.
2) The glass bulb in the sprinkler had drained out of the sprinkler in the Clinic I.T. Room.