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Based on observation and staff interview during the course of the survey conducted on February 22 and 23, 2016, it was determined that the facility failed to maintain the smoke barrier doors in accordance with section 19.3.7.6 of the Life Safety Code.
This was evidenced by the following:

During the walk through with the facility staff:

Smoke barrier doors at PCU Pace Clinic failed to close properly when released.

The smoke barrier door closing deficiency item was discussed during the survey and again during the exit conference.

Based on observation and record review during the course of the survey conducted on February 22 and 23, 2016, it was determined that the facility failed to protect hazardous areas in accordance with section 19.3.2.1 of the Life Safety Code. This was evidenced by the following:

During the walk through with the facility staff:

1. Respiratory supplies were stored in a former bathroom in PCU. The door (a door leading to a corridor) does not have an automatic/self-closer.

2. The door to the laundry area (a door leading to the corridor) did not fully close. The high air pressure in the laundry area did not allow the door to close, not forming the required seal.

3. The door to the Purchasing/Materials Management door did not have an automatic/self-closer.
4. An unsealed vertical penetration was located in the ceiling of the laundry area.

The hazardous area deficiency items were discussed during the survey and again during the exit conference.

Based on observation and staff interview during the course of the survey conducted on February 22 and 23, 2016, it was determined that the facility failed to provide and maintain a means of egress so arranged that exits are readily accessible at all times in accordance with section 19.2.1 of the Life Safety Code. This was evidenced by the following:

During the walk through with the facility staff:

A slide-bolt locking mechanism was on the double doors of the laundry area.

The means of egress deficiency item was discussed during the survey and again at the exit conference.

Based on observation, staff interview, and record review during the course of the survey conducted on February 22 and 23, 2016, it was determined that the facility failed to conduct fire drills in accordance with sections 19.7.1.2 and 4.7 of the Life Safety Code. This was evidenced by the following:

During record review:

Fire drills were not conducted quarterly on each shift to familiarize personnel with the signals and emergency action required under varied conditions in accordance with 19.7.1.2 and 19.7.1.3.

The fire drill deficiency item was discussed during the survey and again during the exit conference.

Based on observation during the course of the survey conducted on Februaru 22 and 23, 2016, it was determined that the facility failed to maintain the Fire Alarm System in accordance with section 19.3.4 of the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

During the walk through with the facility staff:

There were no inspections performed on the fire alarm system.

The fire alarm deficiency item was discussed during the survey and again at the exit conference.

Based on observation during the course of the survey conducted on September 19 and 20, 2012, it was determined that the facility failed to install the automatic fire sprinkler system in accordance with NFPA 13 This was evidenced by the following:
During the walk through with the facility staff:

1) Fire sprinkler spacing in the radiology dressing area was spaced less than the required minimum spacing of 6'.
2) Hydraulic calculation placards not located on the system risers.

The fire sprinkler installation deficiency items were discussed during the survey and again at the exit conference.

Based on observation during the course of the survey conducted on February 22 and 23, 2016, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13 and 25. This was evidenced by the following:
During the walk through with the facility staff:

There were no inspections performed (quarterly, annually) on the automatic fire sprinkler system.

The fire sprinkler maintenance deficiency item was discussed during the survey and again at the exit conference.

Based on observation, staff interview, and record review during the course of the survey conducted on February 22 and 23, 2016, it was determined that the facility failed to maintain penetrations in smoke barriers by ducts in accordance with section 8.3.6 of the Life Safety Code. This was evidenced by the following:
During record review:

The documentation provided by the facility, from an independent contractor dated August 20, 2008 indicated dampers which were not testable. The report indicated that the fire smoke damper separating the laboratory from the corridor contained cables running through the damper obstructing the operation. As a result this opening within a smoke barrier is not protected in accordance with 8.3.6. In addition this damper was not tested within the interval specified by CMS S&C-10-04-LSC.

The damper testing deficiency item was discussed during the survey and again during the exit conference.

Based on observation and record review during the course of the survey conducted on February 22 and 23, 2016, it was determined that the facility failed to store oxygen cylinders in accordance with section 11.6.2.3 of NFPA 99. This was evidenced by the following:

During the walk through with the facility staff:

Oxygen cylinders in the lower level oxygen storage room were not chained/restrained.

The oxygen storage deficiency item was discussed during the survey and again during the exit conference.