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Based on observations and interview, it was determined that the facility failed to ensure that three fire/smoke barrier doors could automatically close to a latched position when released from the magnetic hold-open device and one door failed to be equipped with an automatic door-closing device.

Findings include:

Observations during tour on 08/03/21 and 08/04/21 between 8:00 a.m. and 2:00 p.m. with Staff A (Facilities Director) and Staff B (Assistant Facilities Director) revealed the following four fire/smoke doors and the conditions that exist:
1. The 1-hour fire rated door assembly next to the service elevator (in the corridor to the Cafeteria), the right hand door panel failed to close to a latched position when released from the magnetic-hold open device.
2. The second floor smoke barrier door # 203 B (Physicians Office), failed to automatically close to a latched position when released from the magnetic hold open device.
3. The second floor 90-minute fire rated door assembly # 226 (Charting Office), failed to close to a latched position when released from the magnetic hold-open device.
4. The first floor smoke barrier door, located in the Cardio Pulmonary Unit office corridor, failed to be equipped with an automatic door-closing device.

Interview on 08/03/21 and 08/04/21 with Staff A and Staff B confirmed the above findings, locations, and conditions that exist.

Based on record review and interview, it was determined that the facility failed to ensure that fire drills were held at unexpected times for the 2nd and 3rd shifts.

Findings include:

Record review during tour on 08/03/21 between 9:00 a.m. and 1:00 p.m. with Staff A (Facilities Director) revealed the fire drill logs for the 2nd and 3rd shifts failed to be held at unexpected times.
The fire drill times and dates are as follows:

2nd shift 3:00 p.m. - 11:00 p.m.
07/05/21 7:05 p.m.
04/02/21 8:15 p.m.
01/06/21 8:00 p.m.
10/19/20 3:30 p.m.
07/16/20 3:00 p.m.
04/16/20 3:12 p.m.
01/21/20 3:25 p.m.
10/24/19 3:30 p.m.
07/24/19 3:19 p.m.
04/25/19 3:26 p.m.
01/24/19 3:20 p.m.
10/26/18 3:06 p.m.
07/25/18 3:18 p.m.
04/25/18 3:09 p.m.
01/25/18 3:12 p.m.

3rd shift 11:00 p.m. - 7:00 a.m.
06/05/21 12:31 a.m.
03/02/21 11:30 p.m.
12/14/20 11:20 p.m.
09/17/20 11:30 p.m.
08/06/20 6:00 a.m.
06/11/20 11:30 p.m.
03/17/20 1:00 a.m.
12/20/19 11:30 a.m.
09/26/19 2:45 a.m.
06/21/19 1:00 a.m.
03/29/19 6:00 a.m.
12/21/18 6:02 a.m.
09/26/18 6:32 a.m.
06/27/18 6:28 a.m.
03/26/18 6:30 a.m.
12/29/17 6:43 a.m.

Interview on 08/03/21 with Staff A confirmed the above findings and available documentation.