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Based on observation, fire barrier doors are not maintained to provide separation of building areas. Failure to provide required separations can contribute to the spread of fire & smoke beyond the compartment of fire origin and compromise the safety of building occupants in adjacent compartments.

Findings include:

On 11/02/2021 at 12:44pm, while in the company of the MM it was observed that the 90min rated double doors at the south entrance of the Family Medical Clinic did not self-close to a latched condition to comply with 8.3.3, 8.3.4 and NFPA 80-2010, 6.1.4. The wall is a 2 hour fire barrier which separates the hospital from the Family Medical Clinic.

Based on observation, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Findings include:

On 11/02/2021 at 11:20am, while accompanied by the MM it was observed that the sign above the southeast cross-corridor doors of the patient room wing is installed backwards and is therefore not in compliance with 7.10.3.1.

Based upon observation, hazardous areas are not properly separated from the remainder of the occupancy and the means of egress. Failure to properly separate hazardous area from required means of egress paths can compromise the safety of all occupants. If a fire were to originate in the hazardous area, then the adjacent corridor necessary for exiting would be compromised due to the areas are not being properly separated.

Findings include:

On 11/02/2021 at 1:00pm, while in the company of MM it was observed that the maintenance shop double doors failed to self close to comply with 19.3.2.1.3 and 19.3.6.3.5. because the astragal on the inactive leaf was hitting the latch bolt of the active leaf when the door coordinator was exercised.

Smoke detectors in the facility are not located as required for a compliant fire alarm system installation. Failure to locate devices accordingly may result in failure or delay of alarm initiation device during an emergency event. If alarm initiating devices do not function properly, then the building occupants may not be alerted to an emergency which may result in occupants' safety being compromised.

Findings include:

A. It was observed that detectors are located where airflow may prevent normal operation of the device as stated in NFPA 72-2012, 17.7.4.1. Locations & conditions observed include the following:

1. On 11/02/2021 at 11:15am, while in the company of MM it was observed that a smoke detector was within 3"-0" of an HVAC diffuser in the north corridor of patient room wing.

2. On 11/02/2021 at 11:25am, while in the company of MM it was observed that a smoke detector was within 3"-0" of an HVAC diffuser in the east corridor of patient room wing.

3. On 11/02/2021 at 11:30am, while in the company of MM it was observed that a smoke detector was within 3"-0" of an HVAC diffuser in the Sterile Storage room at the north end of the O.R suite.

4. On 11/02/2021 at 12:30pm, while in the company of MM it was observed that a smoke detector was within 3"-0" of an HVAC diffuser in the Gift Shop.

Based upon observation, construction areas are not properly separated from the remainder of the occupancy and the means of egress. Failure to properly separate construction areas from required means of egress paths can compromise the safety of all occupants. If a fire were to originate in the construction area, then the adjacent egress component necessary for exiting would be compromised due to the areas are not being properly separated.

Findings include:

On 11/02/2021 at 11:14am, while in the company of MM it was observed that the rooms under renovation at the north end of the patient room wing are open to the north exit. Therefore, the facility does not comply with 19.7.9.1. and 4.6.10.

Based on observation, not all portions of the electrical system are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical systems could fail to operate properly when needed if they are not properly installed

Findings include:

On 11/02/21 at 12:41pm, while in the company of the MM it was observed that a coverplate was missing on an electrical junction box above the hospital corridor ceiling at the south entrance of the Family Medical Clinic. Therefore, the electrical system is not installed in compliance with NFPA 70-2011, 314.28(C).