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Based upon observation and interview, the facility failed to ensure that non-healthcare occupancies located immediately next to a health care occupancy were separated by construction having not less than 2-hour fire rated construction and did not serve 4 or more inpatients in accordance with 19.1.3.4.1. This deficient practice could affect all occupants of the lobby and registration area in the event of a uncontrolled fire in the contiguous non-healthcare occupancy.

Findings Include:
In an observation on 9/11/18 at approximately 3:20 PM, a gap exceeding 1/8" was measured at the meeting edges of the 90 minute fire doors at the Medical Office Building entrance. The observed condition is in violation of NFPA 80, Section 6.3.1.7.1.

In an interview on 9/11/18 at approximately 3:20 PM, Facilities Director #1 and Maintenance Supervisor #2 confirmed an excessive gap was measured at the meeting edges of the 90 minute fire doors at the Medical Office Building entrance.

Based upon observation and interview, the facility failed to ensure that aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7 and continuously maintained free of all obstructions to full use in case of an emergency as required by 19.2.1 and 7.1.10.1. This deficient practice could affect all occupants of the smoke compartment in the event of a fire or other emergency requiring instant use of the means of egress.

Findings Include:
In an observation on 9/11/18 at approximately 12:55 PM, idle equipment stored in the Hadley Unit exit access corridor in violation of NFPA 101, Section 7.1.10.1 which reduced the required 8-foot corridor width.

In an interview on 9/11/18 at approximately 12:55 PM, Facilities Director #1 and Maintenance Supervisor #2 confirmed idle equipment stored in the Hadley Unit exit access corridor.

Based upon observation and interview, the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, resist the passage of smoke, equipped with a means suitable for keeping the door closed, and there is no impediment to the closing of doors as required by 19.3.6.3 and 42 CFR 403, 418, 460, 482, 483, and 485. This deficient practice could affect all occupants of the smoke compartment by allowing combustion products to escape to the exit access corridor in the event of a fire.

Findings Include:
In an observation on 9/11/18 at approximately 11:35 AM, corridor door at 2 North Pantry could not be fully closed due to the positioning of materials stored in the door swing radius in violation of NFPA 101, Section 19.3.6.3.

In an interview on 9/11/18 at approximately 11:35 AM, Facilities Director #1 and Maintenance Supervisor #2 confirmed corridor door at 2 North Pantry could not be fully closed due to the positioning of materials stored in the door swing radius.

Based upon observation and interview, the facility failed to ensure that smoke barriers were constructed to a minimum 1/2-hour fire resistance rating in accordance with 8.5 as required by 19.3.7.3 and 8.6.7.1(1). This deficient practice could affect all occupants in the adjoining smoke compartment by allowing smoke passage through the smoke barrier in the event of a fire.

Findings Include:
1. In an observation on 9/11/18 at approximately 11:15 AM, a conduit penetration in 2nd floor east Electrical Room had not been sealed with an approved fire stopping system in accordance with NFPA 101, Section 8.3.5.1

- In an interview on 9/11/18 at approximately 11:15 AM, Facilities Director #1 and Maintenance Supervisor #2 confirmed a conduit penetration in 2nd floor east Electrical Room had not been sealed with an approved fire stopping system.

2. In an observation on 9/11/18 at approximately 11:25 AM, a condensate line penetration in OB Mechanical Room had not been sealed with an approved fire stopping system in accordance with NFPA 101, Section 8.3.5.1

- In an interview on 9/11/18 at approximately 11:25 AM, Facilities Director #1 and Maintenance Supervisor #2 confirmed a condensate line penetration in OB Mechanical Room had not been sealed with an approved fire stopping system.

3. In an observation on 9/11/18 at approximately 1:15 PM, multiple penetrations above ceiling at Hadley north entrance had not been sealed with an approved fire stopping system in accordance with NFPA 101, Section 8.3.5.1

- In an interview on 9/11/18 at approximately 1:15 PM, Facilities Director #1 and Maintenance Supervisor #2 confirmed multiple penetrations above ceiling at Hadley north entrance had not been sealed with an approved fire stopping system.

Based upon record review and interview, the facility failed to ensure that fire drills include the transmission of a fire alarm signal, simulation of emergency fire conditions, are held at unexpected times under varying circumstances, and conducted at least quarterly on each shift as required by 19.7.1.4 through 19.7.1.7. This deficient practice could potentially affect all occupants in the facility if staff are not properly trained in approved emergency procedures.

Findings Include:
During a review of records on 9/11/18 at approximately 10:50 AM, the fire drill documented on 12/21/17 at 3:20 PM was conducted after the time frame identified as 1st shift (7:00 AM to 3:00 PM). This fire drill does not meet the requirements for quarterly drills conducted on each shift in accordance with NFPA 101, Section 19.7.1.6.

In an interview during a review of records on 9/11/18 at approximately 10:50 AM, Maintenance Supervisor #2 confirmed the fire drill documented on 12/21/17 at 3:20 PM was conducted after the time frame identified as 1st shift (7:00 AM to 3:00 PM).