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Based on observations, the facility failed to ensure that corridor doors were maintained in accordance with the recognized Standard in the Environmental Services (E.S.) Staff Lounge and the inner set of cross corridor doors within Surgery. These conditions may allow smoke from a fire to enter an exit corridor and make it untenable.

Findings include:

During tour on June 15, 2011 between 1:30 and 3:00 p.m., the (minimum 20 minute) fire rated corridor door at E.S. had tape over the latching spring bolt and striker plate. At the newly installed (20 minute) fire rated opposing leafs cross corridor door assembly in surgery, the gap between the two leafs exceeds 1/8 of an inch.
Reference: NFPA 80--Standard for Fire Doors and Fire Windows (1999 Edition)
2-3.1.7 The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 inch for steel doors and shall not exceed 1/8 inch for wood doors.

Based on observations, the facility failed to ensure the automatic sprinkler system was completely maintained in the Diagnostic Center X-ray rooms #1 and #2, Gift Shop store room, Medical Staff Office, and the Janitor Closet opposite Physical Therapy. These conditions may affect operating capabilities of the suppression system in the event of a fire.

Findings include:

1. During tour on June 14, 2011 between 11:45 a.m. and 3:30 p.m., in the X-ray rooms #1 and #2, the ceiling sprinkler deflectors were not located the minimum distance below the ceiling.
Reference: NFPA 13--Standard for the Installation of Sprinkler Systems (1999 Edition)
4-6.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 inch and a maximum of 12 inches.

2. During tour on June 14, 2011 between 11:45 a.m. and 3:30 p.m., in the Gift Shop store room, two sprinklers were located too close together. For the type of devices installed they must be a minimum of 6 feet apart.
Reference: NFPA 13--Standard for the Installation of Sprinkler Systems (1999 Edition)
4-6.3.4 Minimum Distance Between Sprinklers. Sprinklers shall be spaced not less than 6 feet on center.

3. During tour on June 15, 2011 between 10:00 a.m. and 12:00 noon in the Medical Staff office recessed ceiling sprinklers were missing the cover plates.
Reference: NFPA 13--Standard for the Installation of Sprinkler Systems (1999 Edition)
2-2.6.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

4. During tour on June 15, 2011 between 10:00 a.m. and 12:00 noon in the Janitor Closet, an existing sprinkler exceeded the allowable distance below the ceiling. It was approximately 3-0 below the underside of the floor above.
Reference: NFPA 13--Standard for the Installation of Sprinkler Systems (1999 Edition)
4-6.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 inch and a maximum of 12 inches.

Based on observation, the facility failed to ensure working exhaust ventilation was provided where required in the Respiratory corridor Housekeeping room adjacent to the Respiratory Control room. This condition may allow airborne pathogens and contaminants to enter adjoining spaces and endanger occupants.

Findings include:

During tour on June 15, 2011 at 2:30 p.m., the Respiratory corridor Housekeeping room adjacent to the Respiratory Control room also utilized as floor machine equipment batteries recharging room, did not have any exhaust ventilation.
Exhaust ventilation direct to atmosphere is required (as examples) in Soiled Linen Storage and Handling, Laundry, Dish Washing, Decontamination or Soiled Workroom, Anesthesia Storage, Laboratories, Sterilizer equipment room, Toilets, Janitors Closets, Baths, Showers, Battery recharging, and Bed Pan rooms. The preceding list of occupancies is not all inclusive.

Based on observations, the facility failed to ensure that corridor doors were maintained in accordance with the recognized Standard in the Environmental Services (E.S.) Staff Lounge and the inner set of cross corridor doors within Surgery. These conditions may allow smoke from a fire to enter an exit corridor and make it untenable.

Findings include:

During tour on June 15, 2011 between 1:30 and 3:00 p.m., the (minimum 20 minute) fire rated corridor door at E.S. had tape over the latching spring bolt and striker plate. At the newly installed (20 minute) fire rated opposing leafs cross corridor door assembly in surgery, the gap between the two leafs exceeds 1/8 of an inch.
Reference: NFPA 80--Standard for Fire Doors and Fire Windows (1999 Edition)
2-3.1.7 The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 inch for steel doors and shall not exceed 1/8 inch for wood doors.

Based on observations, the facility failed to ensure the automatic sprinkler system was completely maintained in the Diagnostic Center X-ray rooms #1 and #2, Gift Shop store room, Medical Staff Office, and the Janitor Closet opposite Physical Therapy. These conditions may affect operating capabilities of the suppression system in the event of a fire.

Findings include:

1. During tour on June 14, 2011 between 11:45 a.m. and 3:30 p.m., in the X-ray rooms #1 and #2, the ceiling sprinkler deflectors were not located the minimum distance below the ceiling.
Reference: NFPA 13--Standard for the Installation of Sprinkler Systems (1999 Edition)
4-6.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 inch and a maximum of 12 inches.

2. During tour on June 14, 2011 between 11:45 a.m. and 3:30 p.m., in the Gift Shop store room, two sprinklers were located too close together. For the type of devices installed they must be a minimum of 6 feet apart.
Reference: NFPA 13--Standard for the Installation of Sprinkler Systems (1999 Edition)
4-6.3.4 Minimum Distance Between Sprinklers. Sprinklers shall be spaced not less than 6 feet on center.

3. During tour on June 15, 2011 between 10:00 a.m. and 12:00 noon in the Medical Staff office recessed ceiling sprinklers were missing the cover plates.
Reference: NFPA 13--Standard for the Installation of Sprinkler Systems (1999 Edition)
2-2.6.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

4. During tour on June 15, 2011 between 10:00 a.m. and 12:00 noon in the Janitor Closet, an existing sprinkler exceeded the allowable distance below the ceiling. It was approximately 3-0 below the underside of the floor above.
Reference: NFPA 13--Standard for the Installation of Sprinkler Systems (1999 Edition)
4-6.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 inch and a maximum of 12 inches.

Based on observation, the facility failed to ensure working exhaust ventilation was provided where required in the Respiratory corridor Housekeeping room adjacent to the Respiratory Control room. This condition may allow airborne pathogens and contaminants to enter adjoining spaces and endanger occupants.

Findings include:

During tour on June 15, 2011 at 2:30 p.m., the Respiratory corridor Housekeeping room adjacent to the Respiratory Control room also utilized as floor machine equipment batteries recharging room, did not have any exhaust ventilation.
Exhaust ventilation direct to atmosphere is required (as examples) in Soiled Linen Storage and Handling, Laundry, Dish Washing, Decontamination or Soiled Workroom, Anesthesia Storage, Laboratories, Sterilizer equipment room, Toilets, Janitors Closets, Baths, Showers, Battery recharging, and Bed Pan rooms. The preceding list of occupancies is not all inclusive.