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Based on observation and document review, building services are not addressed in accordance with Code requirements. Failure to maintain building services and provide multiple safe guards may compromise the safety of any building occupants during a fire emergency.

Finding includes:

On 3/28/2025 while accompanied by the EDO the handling of and disposal of garbage, refuse and solid waste does not comply with 19.1 and 4.5 for any and all means of safe guards from a potential fire emergency. The amount of material waste and combustibles located within areas of the facility and the location of the exterior dumpsters does not provide for an environment that is maintained to prevent fire and other hazards to personal safety to comply 4.5.2. Refer to the following:

1. Due to the condition of the exterior dumpsters near the receiving dock as overflowing their capacity with general and medical waste disposal the condition is not in compliance with grounds and building maintenance and the handling and disposing of waste.

2. Due to the condition of the exterior dumpsters, Trash room and Receiving area used as storage of general and medical waste, The conditions at this facility are conducive to the harborage or breeding of vermin. The hospital site is not in compliance with 4.5.1.

Based on observation, not all egress paths are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress could be impeded under emergency conditions if they are not maintained.

Findings include:

On 3/28/2025 while accompanied by the EDO, observation determined that means of egress are not maintained continuously free of obstructions, as required by 7.1.10.2.1. The means of egress outside of the trash room near the recieving dock was observed to be overflowing with trash, thus presenting a hazard in the egress path.

Based on observation, not all doors required to be self closing are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress could be impeded under emergency conditions if self closing doors not maintained.

Findings include:

On 3/28/2025, while accompanied by the EDO, observation determined that fire and smoke doors are not maintained in accordance with code requirements (NFPA 80, 2010, 5.1.1.1, NFPA 101, 2012, section 19.3.2.1.3, 7.2.1.7 and 8.7. Failure to maintain door assemblies can compromise the safety of any building occupants if the function of the door to restrict the spread of fire & smoke during a fire emergency is undetected. Example location, the Trash room ("Compactor room"?) contained entry doors which did not provide the following:

1. Maintain the required fire rating for the room.
2. There is visible structural damage to the door leaf and door frame.
3. The doors did not self-close or self-latch.
4. The door hardware does not meet the requirements for fire rated assemblies.
5. The door hardware is damaged.
6. Visible large gaps surround the door and frame.

Based on observation during the survey walk-through,Sprinklered hazardous areas are not separated by a minimum fire resistance construction. Failure to separate hazardous areas (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material compromising the use of the adjacent means of egress for exiting.

Finding includes:

On 3/28/2025 while in the company of the EDO it was observed that the condition of the Trash room had been deficient for a period of time and the amount of trash built up. The Trash room contained an immense accumulation of combustibles. Material included cardboard, fabric and plastics when burned releases harmful chemicals all piled within 3- 5 feet of the approximate 10-foot ceiling height. This trash filled the room and is deemed by this AHJ to exceed that required for a healthcare building NFPA 101 19.3.2.1, 19.7.5.7 and 8.7.1.

Based on observation and document review, fire and smoke doors are not maintained in accordance with Code requirements. Failure to conduct and document fire and smoke door inspection and maintenance can compromise the safety of any building occupants if the door assemblies are not maintained as intended to restrict the spread of fire & smoke during a fire emergency.

Finding includes,

A. On 3/28/2025, while in the company of the EDO, documentation review for the Annual Fire and Smoke Door Inspections was not complete to comply with Section 19.7.6, 8.3.3.1, 7.2.1.15, and 2010 Edition of NFPA 80, Section 5.2.4.2. The latest Annual Fire and Smoke Door Inspection report was performed in house in January 2025. There is no indication that the door to the Trash room was inspected. The door contains numerous deficiencies that inhibit its function as a self-closing self-latching fire rated assembly.

B. On 3/28/2025 while in the company of the EDO, Review of the Annual Fire and Smoke Door Inspection indicates an incomplete document and does not comply with Section 19.7.6, 8.3.3.1, 7.2.1.15, and 2010 Edition of NFPA 80, Section
5.2.4.1 and 5.2.4.2. refer to the following:

1. The latest Annual Fire and Smoke Door Inspection report appears incomplete - there are no doors indicated for the hospital other than one on the first floor, penthouse, two doors on the second floor. Due to the number of "pass" comments it appears that these doors are not adequately inspected.
2. For the 2 - 3 doors which indicated "Fail" for item #6 or #8 there is no indication that these failures were corrected.
3. There is no indication on the inspection report that door assemblies are inspected from both sides to access the overall condition (NFPA 80, 2010, 5.2.4.1.)
4. Task comment # 10 "Is the door locking in the path of egress for the clinical needs of the patient?" This door is indicated to have "passed". It is located in the POB lower level there is no information as pertaining to the locking of a door in a means of egress for patient care. From information provided there is no indication of how this door functions to comply with 19.2.2.2.2, 19.2.2.2.5, 19.2.2.2.6.
5. Task comment #15 "Is there only one delayed egress panic bar in the path of egress" there is a note "can apply for waiver" this statement within the inspection report does not comply Part 250 Hospital Licensing Requirements Section 250.2450 c) 2) O).
6. There is no indication that the personnel inspecting the doors qualifies per NFPA 101 2012, section 7.2.1.15.5, NFPA 80, 2010 section 3.3.95.