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Based on observations and staff interview, the facility failed to maintain proper maintenance of the Fire/Smoke doors. This condition could result in (2) Smoke Compartments to become involved in a Fire/Smoke situation. This could allow fire, smoke and fire gasses to enter the compartment which would impede or deny the exiting of occupants in an emergency and result in harm to the occupants from the dangers of the emergency situation.
The findings Include:
During the revisit tour of facility with Maintenance Director and Facility Compliance Officer on 7/23/2015 at 2:30 pm, it was observed that the following rated Fire/Smoke doors were not closing properly, 1) emergency room admittance door and 2) the cross over hallway door. The plan of correction indicated that both doors had been repaired. Upon testing the doors neither door closed properly. The Maintenance Director was able to adjust the cross over hallway door while I was present and have it close properly. During interview with the Maintenance Director, he stated he would have to remove the emergency room admittance door for repair. NFPA 101, (2012 edition,) Chapter 19, 19.3.6.3.5, "Doors shall be provided with a means for keeping the door closed that is acceptable to the AHJ (Authority Having Jurisdiction)."

Based on observations and staff interview, the facility failed to provide audible appliances in an on- call sleeping room area which could negatively affect those within the room by not alerting them to an emergency situation, resulting in the potential endangerment of the occupants of the room in the event of an emergency.
The findings Include:
During the revisit facility tour with the Maintenance Director and Facility Compliance Officer on 7/23/2015 at 2:45 PM, beds were still found in the respiratory sleep room without an audible device for the fire alarm system. During interview, it was confirmed by respiratory staff that he was sleeping in the room because of long hours he worked. The plan of correction indicated that the room had been decommissioned as sleeping quarters. An electrically supervised fire alarm, which provides emergency forces notification, is available to warn occupants, and operate protective systems shall be provided in accordance with NFPA 101 Life Safety Code (2012 edition) 18.3.4 & 19.3.4 & 9.6.