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The facility failed to ensure communicating openings through a two-hour fire resistant rated occupancy separation wall occur only in corridors. 18.1.1.4.2

Observation determined:

1) There was a doorway through the two-hour fire resistant rated occupancy separation wall from the corridor in the clinic to the ER Bay 2 in the hospital.
2) There was a doorway through the two-hour fire resistant rated occupancy separation wall from the corridor in the clinic to the ER Work Room in the hospital.
3) There was a doorway through the two-hour fire resistant rated occupancy separation wall from the corridor in the clinic to the Soiled Utility Room in the hospital.
4) There was a lab pass through opening through the two-hour fire resistant rated occupancy separation wall from the Lab Draw Room in the clinic to the Lab in the hospital.
5) There was a doorway through the two-hour fire resistant rated occupancy separation wall from the Lab Draw Room in the clinic to the Lab in the hospital.
6) There was a doorway through the two-hour fire resistant rated occupancy separation wall from the Lab Draw Room in the clinic to the Lab Draw Toilet Room in the hospital.
7) There was a doorway through the two-hour fire resistant rated occupancy separation wall from the Lab Draw Room in the clinic to the X-ray Technician Room in the hospital.

Failure to ensure communicating openings through two-hour fire resistant rated occupancy separation walls occur only in corridors increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) two-hour fire resistant rated occupancy separation walls in the facility.

Smoke barrier swinging doors in corridors are arranged so that each door swings in an opposite direction. Doors are self-closing and rabbets, bevels or astragals are required at the meeting edges. 18.3.7.5, 18.3.7.6, 18.3.7.8

The facility failed to ensure doors located in smoke barrier walls resisted the passage of smoke.

Observation determined:

1) The cross-corridor doors in the west smoke barrier on the first floor were not equipped with rabbets, bevels or astragals to resist the passage of smoke.
2) The north cross-corridor doors in the east smoke barrier on the first floor were not equipped with rabbets, bevels or astragals to resist the passage of smoke.
3) The south cross-corridor doors in the east smoke barrier on the first floor were not equipped with rabbets, bevels or astragals to resist the passage of smoke.

Failure to ensure doors located in smoke barrier walls resisted the passage of smoke increases the risk of death or injury due to fire.

This deficiency affected two (2) of three (3) smoke barrier walls in the facility.

Observation determined the following doors opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened. 7.2.1.4.4

1) The corridor door to the Oxygen Storage Room on the first floor.
2) The corridor door to the Soiled Laundry Room on the first floor.
3) The corridor door to the Linen Storage Room on the first floor.
4) The corridor door to the Electrical Closet on the second floor.
5) The corridor door to the East Closet on the second floor.

Failure to ensure exit access was readily available at all times increases the risk of death or injury due to fire.

This deficiency affected five (5) of numerous corridor doors in the means of egress throughout the facility.

1) All Level 1 and Level 2 installations of an emergency generator shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. NFPA 110 3-5.5.6

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

Observation determined there was no remote stop switch for the generator located outside of the generator room.

2) Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly. A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. NFPA 110 6-3.4, 6-4.1

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

Review of generator records could not verify that weekly inspections had been conducted in the past year.

Failure to inspect and maintain the emergency generator in accordance with NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.

The facility failed to ensure communicating openings through a two-hour fire resistant rated occupancy separation wall occur only in corridors. 18.1.1.4.2

Observation determined:

1) There was a doorway through the two-hour fire resistant rated occupancy separation wall from the corridor in the clinic to the ER Bay 2 in the hospital.
2) There was a doorway through the two-hour fire resistant rated occupancy separation wall from the corridor in the clinic to the ER Work Room in the hospital.
3) There was a doorway through the two-hour fire resistant rated occupancy separation wall from the corridor in the clinic to the Soiled Utility Room in the hospital.
4) There was a lab pass through opening through the two-hour fire resistant rated occupancy separation wall from the Lab Draw Room in the clinic to the Lab in the hospital.
5) There was a doorway through the two-hour fire resistant rated occupancy separation wall from the Lab Draw Room in the clinic to the Lab in the hospital.
6) There was a doorway through the two-hour fire resistant rated occupancy separation wall from the Lab Draw Room in the clinic to the Lab Draw Toilet Room in the hospital.
7) There was a doorway through the two-hour fire resistant rated occupancy separation wall from the Lab Draw Room in the clinic to the X-ray Technician Room in the hospital.

Failure to ensure communicating openings through two-hour fire resistant rated occupancy separation walls occur only in corridors increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) two-hour fire resistant rated occupancy separation walls in the facility.

Smoke barrier swinging doors in corridors are arranged so that each door swings in an opposite direction. Doors are self-closing and rabbets, bevels or astragals are required at the meeting edges. 18.3.7.5, 18.3.7.6, 18.3.7.8

The facility failed to ensure doors located in smoke barrier walls resisted the passage of smoke.

Observation determined:

1) The cross-corridor doors in the west smoke barrier on the first floor were not equipped with rabbets, bevels or astragals to resist the passage of smoke.
2) The north cross-corridor doors in the east smoke barrier on the first floor were not equipped with rabbets, bevels or astragals to resist the passage of smoke.
3) The south cross-corridor doors in the east smoke barrier on the first floor were not equipped with rabbets, bevels or astragals to resist the passage of smoke.

Failure to ensure doors located in smoke barrier walls resisted the passage of smoke increases the risk of death or injury due to fire.

This deficiency affected two (2) of three (3) smoke barrier walls in the facility.

Observation determined the following doors opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened. 7.2.1.4.4

1) The corridor door to the Oxygen Storage Room on the first floor.
2) The corridor door to the Soiled Laundry Room on the first floor.
3) The corridor door to the Linen Storage Room on the first floor.
4) The corridor door to the Electrical Closet on the second floor.
5) The corridor door to the East Closet on the second floor.

Failure to ensure exit access was readily available at all times increases the risk of death or injury due to fire.

This deficiency affected five (5) of numerous corridor doors in the means of egress throughout the facility.

1) All Level 1 and Level 2 installations of an emergency generator shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. NFPA 110 3-5.5.6

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

Observation determined there was no remote stop switch for the generator located outside of the generator room.

2) Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly. A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. NFPA 110 6-3.4, 6-4.1

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

Review of generator records could not verify that weekly inspections had been conducted in the past year.

Failure to inspect and maintain the emergency generator in accordance with NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.