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Based on observation and interview, the provider failed to maintain the fire-resistive design of one of three occupancy separation openings (cross-corridor doors at main corridor) between the hospital and the clinic. Findings include:

1. Observation at 9:30 a.m. on 7/9/19 revealed the ninety-minute, fire-rated, cross-corridor doors between the hospital and the clinic did not fully close or latch when released from their magnetic hold-opens.

Interview with the maintenance manager at the time of the observation confirmed that finding. Preventative maintenance for the doors included monthly checks during fire drills.

The deficiency could affect 100% of the occupants of the smoke compartment.

Based on observation and interview, the provider failed to arrange exit discharge as required due to abrupt changes in elevation greater than 1/4 inch found at an exit to the public way (old emergency room entrance and staff/receiving entrance). Findings include:

1. On 7/9/19 at the following locations exit discharge did not meet change in elevation requirements. Abrupt changes in elevation of walking surfaces shall not exceed 1/4 inch.
- Old emergency room entrance, two instances of 3/4 in drop
- Staff/receiving entrance, 2 in drop

Ref: 2012 NFPA 101 Section 19.2.7, 7.7.4, 7.1.6.2

The maintenance manager acknowledged the deficiency when it was identified.

Failure to arrange exit discharge as required increases the risk of death or injury due to fire.

The deficiency affected an estimated two of seven exit discharges.

Based on record review and interview, the provider failed to continuously maintain the automatic fire sprinklers in reliable operating condition by doing fire pump churn/no flow tests on a monthly basis during the last year. Findings include:

1. Based on record review at 2:00 p.m. on 7/9/19 the required churn/no flow tests had not been performed in the past year. Quarterly flow tests in the past twelve months had been performed, hence the fire pump had functioned four times.

Interview with maintenance manager at the time of the record review and during the facility tour confirmed that churn/no flow tests had not been performed. There was mention of the required testing in the fire testing manual, but the maintenance manager was unaware of the requirement.

Failure to continuously maintain the automatic fire sprinkler system as required increased the risk of death or injury due to fire.

The deficiency affected one of numerous required tests on the automatic fire sprinkler system.

Reference NFPA 25, 2011 edition, 8.3.1.

Based on observation, testing, and interview, the provider failed to maintain two randomly observed sets of cross-corridor doors adjacent to patient room two and adjacent to patient room ten to form a smoke barrier. Findings include:

1. Observation at 11:15 a.m. on 7/9/19 revealed the cross-corridor, smoke barrier doors near patient room ten would not fully close upon release of the magnetic hold opens. Testing of those doors revealed the doors had swelled and would not close. Interview with the maintenance manager at the time of the observation revealed the smoke barrier doors were checked at least once a month. He confirmed the failure to close at the time of testing.

2. Observation at 1:15 p.m. on 7/9/19 revealed the cross-corridor, smoke barrier doors near patient room two would not fully close upon release of the magnetic hold opens. Testing of those doors revealed the doors had swelled and would not close. The quality assurance staff member who had observed the above confirmed the failure to close at the time of testing.