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Based on observation and interview the facility failed to ensure that 3 sets of Fire/Smoke doors close to a secured, latched position.

Findings include:

Observation during tour on 2/25/15 between 1:00 p.m. and 3:30 p.m. with Staff A (Director of Facilities) revealed the following 3 sets of Fire/Smoke doors that failed to close to a latched position when released from a magnetic hold open device.
1. The set of Fire/Smoke doors between the Oncology suite and the Gift shop in the main hallway failed to close to a latched position.
2. The set of Fire/Smoke doors between the center stairwell and the Doctors office wing (Suite "G") failed to close to a latched position.
3. The set of Fire/Smoke doors between the center stairwell and the Doctors office wing (Suite "A") failed to close to a latched position.

Interview with Staff A at the time of observation confirmed the findings and locations.

Based on observation and interview the facility failed to ensure that 1 oxygen supply storage closet is equipped with an automatic door closing device.

Findings include:

Observation during tour on 2/26/15 between 12:00 p.m. and 3:00 p.m. with Staff A (Director of Facilities) revealed that the Oxygen supply closet on the lower level is not equipped with an automatic door closing device to protect a hazardous area.

Interview with Staff A at the time of observation confirmed the finding.

Based on observation and interview the facility failed to ensure that smoke barriers are maintained to be continuous and could prevent the passage of smoke.

Findings include:

Observation during tour on 2/27/15 between 7:45 a.m. and 12:00 p.m. with Staff A (Director of Facilities) revealed the following locations that have unprotected penetrations through the smoke barrier walls.
1. Above the suspended ceiling near room # GS-160 there are two (2) 5" conduits (with electrical wires inside) that are not sealed inside.
2. Above the suspended ceiling over the smoke barrier doors near the "MRI" room there is one (1) 5" conduit (with wires inside) that is not sealed inside.
3. Above the suspended ceiling near room # GS-183 there is one (1) 5" conduit (with electrical wires inside) that is not sealed inside.
4. Above the suspended ceiling over the smoke barrier doors to the Emergency Department waiting area there is one (1) 5" conduit (with electrical wires inside) that is not sealed inside.
5. Above the suspended ceiling over the smoke barrier doors next to the Library there is a 1 1/2" penetration (with electrical wires) that is not sealed.
6. Above the suspended ceiling in the exit level hallway of stairwell "B" there are three (3) 4" pipes penetrating the fire barrier wall that are not sealed.
7. Above the suspended ceiling near the rear stairwell on the lower level of suite #16 there are two (2)small penetrations from single wires that are not sealed.

Interview with Staff A at the time of observation confirmed the findings and locations.

Based on observation and interview the facility failed to ensure that one (1) EXIT door was accessible for use at all times.

Findings include:

Observation during tour on 2/25/15 between 1:00 p.m. and 3:30 p.m. with Staff A (Director of Facilities) revealed that the EXIT door in the employee hallway behind the "Intensive Care Unit" was blocked by approximately 24" of snow. The opening of the door would have been restricted.

Interview with Staff A at the time of observation confirmed the findings and location.