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Based on observation and interview, the facility failed to ensure that all penetrations through fire rated ceiling construction was protected with approved fire resistant construction. This deficient practice had the potential to expose visitors, patients, and staff to a smoke and fire environment.

Findings:
Observations and interviews during the facility tour on 08/08/2013 at approximately 1:00pm revealed that a fire rated ceiling tile was missing in room 609, pre-op section. The ceiling was insufficient to resist smoke and fire penetration in accordance with NFPA 101, Section 8.2.5.

This observation was acknowledged by the Chief Executive Officer of the Facility.

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Based on observations and interview, the facility failed to ensure that all doors in hazardous areas had self-closing or automatic closing hardware installed to ensure consistent fire and smoke protection. This deficient practice had the potential to expose visitors, patients, and staff to a smoke and fire environment.

Findings:
Observations and interviews during the facility tour on 08/08/2013 at approximately 10:00am revealed that a smoke door for entry into the basement laundry area did NOT have a self-closing or automatic closing hardware installed. The smoke door was insufficient to resist smoke penetration in accordance with NFPA 101, Section 19.3.2.1.

This observation was acknowledged by the Chief Executive Officer of the Facility.

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Based on observation and interview, the facility failed to ensure exit signs were placed in locations to assist with emergency evacuation of the facility. This deficient practice had the potential to expose visitors, patients, and staff to a delay in egress of the facility.

Findings:
Observations and interviews during the facility tour on 08/08/2013 at approximately 10:20am revealed that two (2) egress doors near the loading dock and elevator mechanical room 127 did NOT have exit signs installed in accordance with NFPA 101, Sections 7.10, 18.2.10.1, and 19.2.10.1.

This observation was acknowledged by the Chief Executive Officer of the Facility.

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Based on observation and interview, the facility failed to ensure fire doors that resist the passage of smoke and fire would close properly. This deficient practice had the potential to expose visitors, patients, and staff to a smoke and fire environment.

Findings:
Observation during the facility tour on 08/08/2013 at approximately 1:50pm revealed that a pair of smoke/fire rated doors in the corridor near room 216 and near room 550 did NOT close and latch properly. The pair of smoke/fire rated doors were insufficient to resist the passage of smoke and fire in accordance with NFPA 101, Section 19.3.6.3.

This observation was acknowledged by the Chief Executive Officer of the Facility.

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Based on observation and interview, the facility failed to ensure that the automatic sprinkler system was continuously inspected, tested, and maintained. This deficient practice had the potential to expose visitors, patients, and staff to a smoke and fire environment.

Findings:
Observations during the facility tour on 08/08/2013 at approximately 2:19pm revealed that a fire sprinkler head in the hallway, next to the administration office did NOT have an escutcheon plate installed in accordance with NFPA 101, Section 9.7.5.

This observation was acknowledged by the Chief Executive Officer of the Facility.

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Based on observation, record review, and interview the facility failed to ensure that the kitchen hood and duct suppression system was properly maintained as required by NFPA 96 (1998 edition). This deficient practice had the potential to expose visitors, patients, and staff to a smoke and fire environment.

Findings:
Observations and Review of the Tag of Inspection for the Cafeteria Kitchen Hood and Duct Suppression System on 08/08/2013 at approximately 11:30am revealed that the system was overdue for an annual service and inspection.

This observation was acknowledged by the Chief Executive Officer of the Facility.

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Based on observation and interview, the facility failed to ensure that all penetrations through fire rated ceiling construction was protected with approved fire resistant construction. This deficient practice had the potential to expose visitors, patients, and staff to a smoke and fire environment.

Findings:
Observations and interviews during the facility tour on 08/08/2013 at approximately 1:00pm revealed that a fire rated ceiling tile was missing in room 609, pre-op section. The ceiling was insufficient to resist smoke and fire penetration in accordance with NFPA 101, Section 8.2.5.

This observation was acknowledged by the Chief Executive Officer of the Facility.

.

Based on observations and interview, the facility failed to ensure that all doors in hazardous areas had self-closing or automatic closing hardware installed to ensure consistent fire and smoke protection. This deficient practice had the potential to expose visitors, patients, and staff to a smoke and fire environment.

Findings:
Observations and interviews during the facility tour on 08/08/2013 at approximately 10:00am revealed that a smoke door for entry into the basement laundry area did NOT have a self-closing or automatic closing hardware installed. The smoke door was insufficient to resist smoke penetration in accordance with NFPA 101, Section 19.3.2.1.

This observation was acknowledged by the Chief Executive Officer of the Facility.

.

Based on observation and interview, the facility failed to ensure exit signs were placed in locations to assist with emergency evacuation of the facility. This deficient practice had the potential to expose visitors, patients, and staff to a delay in egress of the facility.

Findings:
Observations and interviews during the facility tour on 08/08/2013 at approximately 10:20am revealed that two (2) egress doors near the loading dock and elevator mechanical room 127 did NOT have exit signs installed in accordance with NFPA 101, Sections 7.10, 18.2.10.1, and 19.2.10.1.

This observation was acknowledged by the Chief Executive Officer of the Facility.

.

Based on observation and interview, the facility failed to ensure fire doors that resist the passage of smoke and fire would close properly. This deficient practice had the potential to expose visitors, patients, and staff to a smoke and fire environment.

Findings:
Observation during the facility tour on 08/08/2013 at approximately 1:50pm revealed that a pair of smoke/fire rated doors in the corridor near room 216 and near room 550 did NOT close and latch properly. The pair of smoke/fire rated doors were insufficient to resist the passage of smoke and fire in accordance with NFPA 101, Section 19.3.6.3.

This observation was acknowledged by the Chief Executive Officer of the Facility.

.

Based on observation and interview, the facility failed to ensure that the automatic sprinkler system was continuously inspected, tested, and maintained. This deficient practice had the potential to expose visitors, patients, and staff to a smoke and fire environment.

Findings:
Observations during the facility tour on 08/08/2013 at approximately 2:19pm revealed that a fire sprinkler head in the hallway, next to the administration office did NOT have an escutcheon plate installed in accordance with NFPA 101, Section 9.7.5.

This observation was acknowledged by the Chief Executive Officer of the Facility.

.

Based on observation, record review, and interview the facility failed to ensure that the kitchen hood and duct suppression system was properly maintained as required by NFPA 96 (1998 edition). This deficient practice had the potential to expose visitors, patients, and staff to a smoke and fire environment.

Findings:
Observations and Review of the Tag of Inspection for the Cafeteria Kitchen Hood and Duct Suppression System on 08/08/2013 at approximately 11:30am revealed that the system was overdue for an annual service and inspection.

This observation was acknowledged by the Chief Executive Officer of the Facility.

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