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Based on observations and testing, the facility failed to properly maintain door openings in smoke barrier walls in accordance NFPA 101 section 19.2.2.3. These condition deficiency practices affect the entire Main Hospital building of the facility.

Findings Include:

On October 30, 2018, at 1:20 PM, observation revealed all the smoke barrier doors in the Main Hospital section of the facility did not properly close upon activation of the fire alarm system.
Observation also revealed the smoke barrier doors in the Intensive Care Unit (ICU) North of the facility did not closed upon activation of the fire alarm system. The smoke barrier doors in the ICU North of the facility were held in the open position by sensor.

Based on observations, the facility failed to properly protect vertical openings in accordance to NFPA 101 section 19.3.1.1. These standard deficiency practices affect the entire Ambulatory Surgery Center (ASC) building of the facility.

Findings Include:

During the building inspection on October 29, 2018 at 10:40 AM, observation revealed unprotected, large polyvinyl chloride (PVC) pipes in the floor ceiling assembly of the Mechanical Rooms in the Ambulatory Surgery Center (ASC) building of the facility. The large PVC pipes (4 inches in diameter) were penetrating the floor ceiling assembly in the mechanical rooms on every floor of the ASC facility and the PVC pipes did not contain protective fire collars.

Based on observation and testing, the facility failed to properly protect corridor openings as directed by NFPA 101 section 19.3.6.3.5. These standard deficiency practices affect the entire Main Hospital building of the facility.

Findings include:

On October 30, 2018, observation revealed the following corridor doors were incapable of positive latching in the Main Hospital building:

1) 6th floor Utilization Room door
2) Doors to X-ray Rooms 5 and 6 in the basement of the facility
3) The Bio-Hazard Room door near the Pharmacy of the facility
4) Doors to X-ray Rooms 2 and 3

Based on observation, the facility failed to properly protect corridor openings as directed by NFPA 101 section 19.3.6.4.1. These standard deficiency practices affect the entire Main Hospital building of the facility.

Findings include:

On October 30, 2018 at 1:30 PM, observation revealed an air transfer grille in the Communications Closet door on the 6th floor in the Main Hospital building of the facility.
The door to the Communications Closet was incapable of limiting the transfer of smoke throughout the facility.

Based on observations, the facility failed to properly maintain smoke barrier walls for the purpose of providing one (1) half hour fire resistance as directed by NFPA 101 section 8.5.6. These condition deficiency practices affect the entire Main Hospital and Ambulatory Surgery Center (ASC) buildings of the facility.


Findings include:

On October 29-30 2018, observation revealed unsealed penetrations in the smoke barrier walls in the following areas of the facility:

1) The smoke barrier walls on the 3rd and 4th floors of the Main Hospital terminated at the underside of a solid ceiling. The solid ceilings contain numerous unsealed penetrations on the 3rd and 4th floors of the Main Hospital.
2) The smoke barrier walls on 2nd floor of the Main Hospital contain unsealed penetrations.
3) The smoke barrier walls on all 5 floors of the ASC Building contain unsealed and improperly sealed penetrations.

*The 2nd, 3rd, and 4th floors of the Main Hospital each contain four (4) smoke compartments.

**Each of the 5 floors of the Ambulatory Surgery Center (ASC) building contains 1 smoke barrier wall.

Based on observations and testing, the facility failed to properly maintain door openings in smoke barrier walls as per NFPA 101 section 19.3.7.8. These standard deficiency practices affect the entire Main Hospital building of the facility.

Findings Include:

On October 30, 2018, observation revealed the following smoke door issues in the basement Main Hospital building of the facility:

1) The smoke barrier door near the CT Room did not properly close.
2) The smoke barrier door near the Main Switch Gear Room lacked an automatic door closer
3) The smoke barrier door near MRI Room 2 lacked an automatic closer.