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Based on observations and testing, the facility failed to properly maintain the exit discharge as required by NFPA 101 sections 19.2.1 & 7.1.10.1. The deficiency affected one (1) of eight (8) exits in the facility on the day of the survey.

Findings Include:

On 2/22/17 at 11:59 AM, outside observation revealed E.R. Ambulance Entry magnetic lock exit does not release upon activation of the fire alarm system.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 2/22/17.

Based on observations, the facility failed to protect vertical openings in accordance with NFPA 101 Section 19.3.1.1 and 8.6. The deficient practice affected two (2) of ten (10) smoke compartments.

Findings Include:

On 2/22/17 at 1:48PM, observation revealed the laundry chute door (near Room E160) lacked automatic closing device. This laundry chute was open to the main corridor of the facility.
The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 2/22/17.

Based on observations, the facility failed to protect hazardous areas in accordance with NFPA 101 section 19.3.2.1, 8.4 and 8.7.1. The deficient practice affected two (2) of ten (10) smoke compartments on the day of the survey.

Findings Include:

On 2/22/17 at 1:25 PM, observation revealed the following deficiencies of the hazardous areas of the facility:
1. Unsprinkled Storage Room across from E168 not separated above ceiling.
2. North Wound Care File Room (used as storage) door requires door closer
3. Room N136 lacked a door closer.
4. Closet (used as storage) next to Room E161 needed a door closer.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 2/22/17.

Based on observations, the facility failed to protect corridors in accordance with NFPA 101 section 19.3.6.1 and 19.3.4.5.2. The deficient practice affected one (1) of ten (10) smoke compartments on the day of the survey.

Findings Include:
On 2/22/17 at 1:08PM, observation revealed the Coffee Break Room (across from Room E148) was protected by a hardwired smoke detector. The Coffee Break Room was open to the main corridor of the facility.
The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 2/22/17.

Based on document review, the facility failed to provide the required quarterly sprinkler system testing in accordance with NFPA 101 Section 9.7.5, 9.7.7 and NFPA 25 Section1-8.2. The deficient practice affected ten (10) of ten (10) smoke compartments.

Findings Include:

While reviewing sprinkler documentation on 2/22/17 at 11:10 AM, observation revealed the facility did not provide any quarterly inspection records for fire sprinkler system.
The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 2/22/17.

Based on observations, the facility failed to maintain portable fire extinguishers in accordance with NFPA 101 section 19.3.5.12 and NFPA 10 code 7.2.3.1. The deficient practice affected ten (10) of ten (10) compartments on the day of the survey.

Findings Include:

On 2/22/17 at 2:45PM, observation revealed all the ABC-class extinguishers in the facility were overdue and required 6 year hydrostatic testing maintenance testing.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 2/22/17.

Based on observations, the facility failed to properly protect corridor openings, in accordance with NFPA 101 section 19.3.6.3. The deficient practice affected six (6) of ten (10) smoke compartments on the day of the survey.

Findings Include:

On 2/22/17 at 11:45 AM, observation revealed the following door deficiencies in the facility:

1) X-ray Door near Surgery Suite has lock higher than 48 inches
2) Surgery Suite has lock higher than 48 inches
3) Room N125 has lock higher than 48 inches
4) Kitchen Door has lock higher than 48 inches and was obstructed by a wooden door kick stop
5) Electrical Room Double Door at the stationary side requires a door closer to ensure positive latching
6) E.R. Trama Room door to corridor has no positive latching
7) E.R Suite door to corridor has open penetration and was obstructed by a wooden door kick stop
8) Gift Shop door was obstructed by a wooden door kick stop
9) Break Room door closer needs adjustment and has no positive latching
10) Clean Linen Door next to Room N136 has open penetration
11) Computer closet, across from Room E147, has open penetration
12) Pharmacy Dutch doors require positive latching on top leaf
13) Surgery Suite Sterol Processing Dutch door requires positive latching on top leaf

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 2/22/17.

Based on observations and interviews, the facility failed to properly maintain smoke barrier walls in accordance to NFPA 101 section 19.3.7.3.
Findings Include:
On 2/22/17 at 12:50 PM, the facility could not provide a smoke compartment plan. Observations revealed unsealed penetrations in what were proposed to be smoke barrier walls. The ceiling appears to serve as part of the smoke wall as the walls did not extend above the solid ceiling to the roof deck and there were penetrations in it as well.
The Maintenance Supervisor stated completed smoke compartment plan will be provided and all open penetrations in the smoke barrier walls will be sealed with the approved fire rated sealant.
The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 2/22/17.

Based on observations, the facility failed to properly protect smoke barrier doors in accordance with NFPA 101 sections 19.3.7.6 and 19.3.7.8. The deficient practice affected two (2) of ten (10) smoke compartments on the day of the survey.

Findings Include:

On2/22/17 at 2:30PM, observation revealed the following smoke barrier door deficiencies of the facility:

1. Smoke barrier doors near N102 did not close completely and needed door closer adjustment.
2. Smoke barrier door near Nurses Station Med Room (across from Room E149) need a door closer.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 2/22/17.