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Based on observations and testing, the facility failed to maintain the doors protecting the corridors.

The findings included:

1. Observation on 8/3/15 at 10:23 AM, revealed the bottom of the fire doors did not latch to the floor in the following locations: next to women's bathroom in main corridor, next to room 101, near medical surgery patient rooms, near progressive care unit, inside the surgery corridor, inside the operating room corridor, and across from engineering services room. NFPA 80, 3-4 (1999 Edition)

2. Observation of the registration office on 8/3/15 at 10:28 AM, revealed fire door was warp. NFPA 80, 15-2 (1999 Edition)

These findings were verified by the plant operations director during the survey and acknowledged by the chief executive officer during the exit conference on 8/3/15.

Based on observations, the facility failed to maintain the exits signs.

The findings included:

Observation of the main corridor helicopter pad exit on 8/3/2015 at 11:20 AM, revealed the exit sign was not illuminated. NFPA 101, 7.10.5.1 (2000 Edition)

This finding was verified by the plant operations director during the survey and acknowledged by the chief executive officer during the exit conference on 8/3/15.

Based on observations, the facility failed to comply with the required adopted smoking regulations.

The findings included:

Observation of the outside designated smoking areas on 8/3/15 at 11:30 AM, revealed the facility failed to provide metal containers with self-closing cover devices into which ashtrays can be emptied readily available where smoking was permitted. National Fire Protection Association (NFPA) 101, 19.7.4 (2000 Edition)

This finding was verified by the plant operations director during the survey and acknowledged by the chief executive officer during the exit conference on 8/3/15.

Based on observations, the facility failed to maintain the cooking facilities.

The findings included:

1. Observation of the kitchen on 8/3/15 at 11:53 AM, revealed the deep fat fryer and stove were not centered under the kitchen's hood extinguishing nozzles. NFPA 96, 7-2.2.1 (1998 Edition)

2. Observation of the kitchen on 8/3/2015 at 11:55 AM, revealed there was no placard identifying the use of the K type fire extinguisher as a secondary backup means to the automatic fire suppression system. The placard shall be conspicuously placed near each portable K type fire extinguisher in the cooking area. NFPA 96, 7-2.1.1 (1998 Edition)

These findings were verified by the plant operations director during the survey and acknowledged by the chief executive officer during the exit conference on 8/3/15.

Based on observations, the facility failed to maintain the corridor walls and the fire door labels.

The findings included:

1. Observation on 8/3/2015 at 10:20 AM, revealed the fire doors' and frame labels were painted in the following locations: near the dining room and near medical records. NFPA 80, 1-5.2

2. Observation on 8/30/2015 at 10:49 AM, revealed the corridor walls were not fully constructed to the roofing deck assembly in the following locations:
A. Main corridor above dining hall, waiting area above dining hall.
B. Waiting area above administration offices.
C. Main corridor above administration offices.
NFPA 101, 19.3.6.2.1 (2000 Edition)

3. Observation on 8/30/2015 at 10:55 AM, revealed penetrations in the corridor walls and the walls were not sealed at the roofing deck assembly in the following locations:
A. Main corridor above dining hall, waiting area above dining hall.
B. Waiting area above administration offices.
C. Main corridor above administration offices.
E. Main corridor above respiratory and medical record rooms.
F. Firewall above cross corridor fire doors near medical surgery patient rooms.
G. Radiology corridor.
NFPA 101, 19.3.6.2.1 (2000 Edition)

These findings were verified by the plant operations director during the survey and acknowledged by the chief executive officer during the exit conference on 8/3/15.

Based on observations and testing, the facility failed to maintain the doors protecting the corridors.

The findings included:

1. Observation on 8/3/15 at 10:23 AM, revealed the bottom of the fire doors did not latch to the floor in the following locations: next to women's bathroom in main corridor, next to room 101, near medical surgery patient rooms, near progressive care unit, inside the surgery corridor, inside the operating room corridor, and across from engineering services room. NFPA 80, 3-4 (1999 Edition)

2. Observation of the registration office on 8/3/15 at 10:28 AM, revealed fire door was warp. NFPA 80, 15-2 (1999 Edition)

These findings were verified by the plant operations director during the survey and acknowledged by the chief executive officer during the exit conference on 8/3/15.

Based on observations, the facility failed to maintain the exits signs.

The findings included:

Observation of the main corridor helicopter pad exit on 8/3/2015 at 11:20 AM, revealed the exit sign was not illuminated. NFPA 101, 7.10.5.1 (2000 Edition)

This finding was verified by the plant operations director during the survey and acknowledged by the chief executive officer during the exit conference on 8/3/15.

Based on observations, the facility failed to comply with the required adopted smoking regulations.

The findings included:

Observation of the outside designated smoking areas on 8/3/15 at 11:30 AM, revealed the facility failed to provide metal containers with self-closing cover devices into which ashtrays can be emptied readily available where smoking was permitted. National Fire Protection Association (NFPA) 101, 19.7.4 (2000 Edition)

This finding was verified by the plant operations director during the survey and acknowledged by the chief executive officer during the exit conference on 8/3/15.

Based on observations, the facility failed to maintain the cooking facilities.

The findings included:

1. Observation of the kitchen on 8/3/15 at 11:53 AM, revealed the deep fat fryer and stove were not centered under the kitchen's hood extinguishing nozzles. NFPA 96, 7-2.2.1 (1998 Edition)

2. Observation of the kitchen on 8/3/2015 at 11:55 AM, revealed there was no placard identifying the use of the K type fire extinguisher as a secondary backup means to the automatic fire suppression system. The placard shall be conspicuously placed near each portable K type fire extinguisher in the cooking area. NFPA 96, 7-2.1.1 (1998 Edition)

These findings were verified by the plant operations director during the survey and acknowledged by the chief executive officer during the exit conference on 8/3/15.

Based on observations, the facility failed to maintain the corridor walls and the fire door labels.

The findings included:

1. Observation on 8/3/2015 at 10:20 AM, revealed the fire doors' and frame labels were painted in the following locations: near the dining room and near medical records. NFPA 80, 1-5.2

2. Observation on 8/30/2015 at 10:49 AM, revealed the corridor walls were not fully constructed to the roofing deck assembly in the following locations:
A. Main corridor above dining hall, waiting area above dining hall.
B. Waiting area above administration offices.
C. Main corridor above administration offices.
NFPA 101, 19.3.6.2.1 (2000 Edition)

3. Observation on 8/30/2015 at 10:55 AM, revealed penetrations in the corridor walls and the walls were not sealed at the roofing deck assembly in the following locations:
A. Main corridor above dining hall, waiting area above dining hall.
B. Waiting area above administration offices.
C. Main corridor above administration offices.
E. Main corridor above respiratory and medical record rooms.
F. Firewall above cross corridor fire doors near medical surgery patient rooms.
G. Radiology corridor.
NFPA 101, 19.3.6.2.1 (2000 Edition)

These findings were verified by the plant operations director during the survey and acknowledged by the chief executive officer during the exit conference on 8/3/15.