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Based on observations, the facility failed to properly maintain door within smoke barrier walls, in accordance with NFPA 101 section 19.2.2.2.7. The deficient practice affected two (2) of six (6) smoke compartments on the day of the survey.

Findings Include:

On 3/14/17 at 11:45 AM, observation revealed the following doors did not have the required door closers:

1) CT Doors
2) Admissions
3) Drug Room

These doors were also located within a smoke barrier wall in the facility. The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/14/17.

Based on observations, the facility failed to properly protect hazardous areas in accordance to NFPA 101 section 19.3.2.1. This deficiency affected one (1) of six (6) smoke compartments in the facility on the day of survey.
Findings Include:
On 3/14/17 at 11:50 AM, observation revealed the following deficiencies of the hazardous areas of the facility:

1. Unsealed penetrations in the wall of the Mechanical Room
2. A closet (75 square feet area) next to Room E161 was being used for storage of boxes. This closet door also requires a door closer.
3. Autoclave Room (375 SQ. FT.) was being used as storage for kitchen equipment. This Autoclave Room door also requires a door closer.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/14/17.

Based on observations, the facility failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building as directed in NFPA 13-8.6.2.2, 8.6.4.1.1.1. This condition affected one (1) of six (6) smoke compartments in the building at the time of survey.
Findings include:
On 3/14/17 at 11:30 AM, observation revealed the following were not completely protected by automatic sprinkler system:
1. X-Ray Room
2. Lab
3. Dark Room
4. Janitor Storage Room at Loading Dock
The sprinkler head in these rooms were installed 18 inches below the ceiling. The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/14/17.

Based on observations, the facility failed to maintain portable fire extinguishers in accordance with NFPA 101 section 19.3.5.12 and NFPA 10 code 7.2.3.1. The deficient practice affected one (1) of six (6) compartments in the facility on the day of the survey.

Findings Include:

On 3/14/17 at 2:45PM, observation revealed K?class extinguisher in the Kitchen was overdue for the 6 year hydrostatic testing maintenance by a certified contractor.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/14/17.

Based on observations the facility failed to provide the proper smoke barrier doors in accordance too NFPA 101 section 19.3.7.6. This deficient practice has the potential of affecting two (2) of six (6) smoke compartments in the facility on day of survey.
Findings Include:
On 3/14/17 at 12:45 PM, observation revealed the smoke barrier doors on Admissions Office and Triage Room did not have automatic closing devices. These doors were located in a smoke barrier wall and did not close upon activation of the fire alarm system.
The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 3/14/17.

Based on observations and document review, the facility failed to provide documentation for space heater per NFPA 101 section 19.7.8. This deficiency affected one (1) of six (6) smoke compartments in the facility on the day of survey.
Findings Include:
On 3/14/17 at 11:50 AM, observation revealed a gas powered space heater in the Maintenance Director Office of the facility. The Maintenance Director was unable to provide the documentation showing the vented space heater element do not exceed 212 degrees Fahrenheit.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/14/17.