HospitalInspections.org

Based on observation and interview, the provider failed to maintain the fire-resistive design of one of two horizontal exits (between the original building and the addition). Findings include:

1. Observation on 3/13/23 at 2:45 p.m. revealed the two-hour, fire-rated separation wall between the original building and the addition had ninety-minute, fire-rated doors with one-half inch gap between the doors. The doors were to provide protection from smoke and fire, but could provide the protection because of the gap between the doors.

Interview at the time of the observation with the director of maintenance confirmed that condition. He showed where he had installed a rubber astrigal, but it could not provide an adequate smoke seal between the doors.

Based on observation and interview, the provider failed to maintain a hazardous area (central supply room) as required. Findings include:

1. Observation on 3/13/23 at 3:30 p.m. revealed the central supply room was over 100 square feet and had large amounts of combustibles stored in it. The door was not equipped with a closer.

Interview with the maintenance technician at the time of the observations confirmed this finding.

The deficiency affected one of numerous requirements for hazardous storage rooms and had the potential to affect 100% of the occupants of the smoke compartment.