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Based on record review, interview, and observation the facility failed to maintain smoke compartments as shown on the facility's layout.

Findings include:

During tour of the facility on 6/26/13 with Staff A (Director of Maintenance) it was revealed that the smoke barrier that separates the hospital into two distinct smoke compartments of 20,555 sq ft (square feet) and the other of 22,441 sq ft fails to be complete, per facility layout. The area that does not meet the standards of a smoke barrier is located by the reception area for day surgery. The two areas where the smoke barrier fails are as follows: over the double doors of the smoke barrier and the back wall of the reception area. The failure is due to barrier not extending to the sub-deck/roof.

Interview with Staff A on 6/26/13 confirmed that the smoke barrier that separates the hospital into two distinct smoke compartments of 20,555 sq ft (square feet) and the other of 22,441 sq ft fails to be complete. The area that does not meet the standards of a smoke barrier is located by the reception area for day surgery. The two areas where the smoke barrier fails are as follows: over the double doors of the smoke barrier and the back wall of the reception area. The failure is due to barrier not extending to the sub-deck/roof.


Cross refer to K 025

Based on record review, interview, and observation the facility failed to construct smoke compartments as shown on the facility's layout.

Findings include:

During tour of the facility on 6/26/13 with Staff A (Director of Maintenance) it was revealed that the smoke barrier that separates the hospital into two distinct smoke compartments of 20,555 sq ft (square feet) and the other of 22,441 sq ft fails to be complete, per facility layout. The area that does not meet the standards of a smoke barrier is located by the reception area for day surgery. The two areas where the smoke barrier fails are as follows: over the double doors of the smoke barrier and the back wall of the reception area. The failure is due to barrier not extending to the sub-deck/roof.

Interview with Staff A on 6/26/13 confirmed that the smoke barrier that separates the hospital into two distinct smoke compartments of 20,555 sq ft (square feet) and the other of 22,441 sq ft fails to be complete. The area that does not meet the standards of a smoke barrier is located by the reception area for day surgery. The two areas where the smoke barrier fails are as follows: over the double doors of the smoke barrier and the back wall of the reception area. The failure is due to barrier not extending to the sub-deck/roof.

Cross refer to K 024

Based on record review, interview, and observation the facility failed to maintain the smoke compartment by failing to have a door closer on a door located within the smoke barrier.

Findings include:

During tour of the facility on 6/26/13 with Staff A (Director of Maintenance) it was revealed that the smoke barrier that separates the hospital into two distinct smoke compartments of 20,555 sq ft (square feet) and the other of 22,441 sq ft failed to have a door closer for the door labeled as the mail room, as indicated on facility layout.

Interview with Staff A on 6/26/13 confirmed that the smoke barrier that separates the hospital into two distinct smoke compartments of 20,555 sq ft (square feet) and the other of 22,441 sq ft failed to have a door closer for the door labeled as the mail room.

Based on record review and interview the facility failed to conduct fire drills at least quarterly on each shift.

Findings include:

Review of facility records revealed the facility has two shifts, the first shift, 7 a.m. to 7 p.m. and second shift 7 p.m. to 7 a.m.. Records reveal that fire drills for the fourth quarter of 2012 and the first quarter of 2013 were only done on the first shift.

Interview of Staff A (Director of Maintenance) confirmed that the facility has two shifts, the first shift, 7 a.m. to 7 p.m. and second shift 7 p.m. to 7 a.m. and that the fire drills for the fourth quarter of 2012 and the first quarter of 2013 were only done on the first shift.

Based on record review, interview, and observation the facility failed to maintain smoke compartments as shown on the facility's layout.

Findings include:

During tour of the facility on 6/26/13 with Staff A (Director of Maintenance) it was revealed that the smoke barrier that separates the hospital into two distinct smoke compartments of 20,555 sq ft (square feet) and the other of 22,441 sq ft fails to be complete, per facility layout. The area that does not meet the standards of a smoke barrier is located by the reception area for day surgery. The two areas where the smoke barrier fails are as follows: over the double doors of the smoke barrier and the back wall of the reception area. The failure is due to barrier not extending to the sub-deck/roof.

Interview with Staff A on 6/26/13 confirmed that the smoke barrier that separates the hospital into two distinct smoke compartments of 20,555 sq ft (square feet) and the other of 22,441 sq ft fails to be complete. The area that does not meet the standards of a smoke barrier is located by the reception area for day surgery. The two areas where the smoke barrier fails are as follows: over the double doors of the smoke barrier and the back wall of the reception area. The failure is due to barrier not extending to the sub-deck/roof.


Cross refer to K 025

Based on record review, interview, and observation the facility failed to construct smoke compartments as shown on the facility's layout.

Findings include:

During tour of the facility on 6/26/13 with Staff A (Director of Maintenance) it was revealed that the smoke barrier that separates the hospital into two distinct smoke compartments of 20,555 sq ft (square feet) and the other of 22,441 sq ft fails to be complete, per facility layout. The area that does not meet the standards of a smoke barrier is located by the reception area for day surgery. The two areas where the smoke barrier fails are as follows: over the double doors of the smoke barrier and the back wall of the reception area. The failure is due to barrier not extending to the sub-deck/roof.

Interview with Staff A on 6/26/13 confirmed that the smoke barrier that separates the hospital into two distinct smoke compartments of 20,555 sq ft (square feet) and the other of 22,441 sq ft fails to be complete. The area that does not meet the standards of a smoke barrier is located by the reception area for day surgery. The two areas where the smoke barrier fails are as follows: over the double doors of the smoke barrier and the back wall of the reception area. The failure is due to barrier not extending to the sub-deck/roof.

Cross refer to K 024

Based on record review, interview, and observation the facility failed to maintain the smoke compartment by failing to have a door closer on a door located within the smoke barrier.

Findings include:

During tour of the facility on 6/26/13 with Staff A (Director of Maintenance) it was revealed that the smoke barrier that separates the hospital into two distinct smoke compartments of 20,555 sq ft (square feet) and the other of 22,441 sq ft failed to have a door closer for the door labeled as the mail room, as indicated on facility layout.

Interview with Staff A on 6/26/13 confirmed that the smoke barrier that separates the hospital into two distinct smoke compartments of 20,555 sq ft (square feet) and the other of 22,441 sq ft failed to have a door closer for the door labeled as the mail room.

Based on record review and interview the facility failed to conduct fire drills at least quarterly on each shift.

Findings include:

Review of facility records revealed the facility has two shifts, the first shift, 7 a.m. to 7 p.m. and second shift 7 p.m. to 7 a.m.. Records reveal that fire drills for the fourth quarter of 2012 and the first quarter of 2013 were only done on the first shift.

Interview of Staff A (Director of Maintenance) confirmed that the facility has two shifts, the first shift, 7 a.m. to 7 p.m. and second shift 7 p.m. to 7 a.m. and that the fire drills for the fourth quarter of 2012 and the first quarter of 2013 were only done on the first shift.