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The facility did not ensure that doors in the fire separation walls, hazardous area enclosures, horizontal exits or smoke partitions were held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the required manual alarm system and either a required smoke detection system and automatic sprinkler system as required by the referenced LSC.

On 10/19/11 at 11:45 A.M., the surveyor while accompanied by the Chief Engineer observed that the doors in the smoke barrier walls, located in the Emergency Department were not held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the required manual alarm system and either a required smoke detection system and automatic sprinkler system as required by the referenced LSC; i.e. the doors to the examination rooms, in the emergency department were provided with hardware that does not release with fire alarm activation.

The facility did not ensure that Portable space heating devices were prohibited as required by section # 19.7.8 of the referenced, Life Safety Code.

On 10/19/11 at 10:30 A.M., the surveyor while accompanied by the Chief Engineer observed that portable, space heating devices were located in both the Clean Utility Room and Soiled Utility Rooms in the Obstetrics Department and are prohibited in all health care occupancies by section # 19.7.8 of the referenced, Life Safety Code; i.e. 3 (three) electric heaters found in Clean Utility and 1 (one) heater found in Soiled Utility.

The facility did not ensure that all employees are periodically instructed as to their duties during a fire emergency as required by NFPA 101 " Life Safety Code " 19.7.1 and annually as required in NFPA 99 " Health Care Facility ' s " 11-5.3.8.

On 10/20/11 at 2:00 PM, the surveyor was not provided with documentation from the Physical Plant Director to indicate that all employees are in serviced as to their duties during a fire emergency as required by NFPA 101 " Life Safety Code " , section 19.7.1 and annually as required in NFPA 99 " Health Care Facility ' s " , section 11-5.3.8.

The facility did not ensure that doors in the fire separation walls, hazardous area enclosures, horizontal exits or smoke partitions were held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the required manual alarm system and either a required smoke detection system and automatic sprinkler system as required by the referenced LSC.

On 10/19/11 at 11:45 A.M., the surveyor while accompanied by the Chief Engineer observed that the doors in the smoke barrier walls, located in the Emergency Department were not held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the required manual alarm system and either a required smoke detection system and automatic sprinkler system as required by the referenced LSC; i.e. the doors to the examination rooms, in the emergency department were provided with hardware that does not release with fire alarm activation.

The facility did not ensure that Portable space heating devices were prohibited as required by section # 19.7.8 of the referenced, Life Safety Code.

On 10/19/11 at 10:30 A.M., the surveyor while accompanied by the Chief Engineer observed that portable, space heating devices were located in both the Clean Utility Room and Soiled Utility Rooms in the Obstetrics Department and are prohibited in all health care occupancies by section # 19.7.8 of the referenced, Life Safety Code; i.e. 3 (three) electric heaters found in Clean Utility and 1 (one) heater found in Soiled Utility.

The facility did not ensure that all employees are periodically instructed as to their duties during a fire emergency as required by NFPA 101 " Life Safety Code " 19.7.1 and annually as required in NFPA 99 " Health Care Facility ' s " 11-5.3.8.

On 10/20/11 at 2:00 PM, the surveyor was not provided with documentation from the Physical Plant Director to indicate that all employees are in serviced as to their duties during a fire emergency as required by NFPA 101 " Life Safety Code " , section 19.7.1 and annually as required in NFPA 99 " Health Care Facility ' s " , section 11-5.3.8.