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Based on observation and interview, the facility failed to maintain three of seven smoke and fire barriers in accordance with 8.3 and 19.3.7.5 to ensure a minimum one half-hour fire resistance rating and prevent the spread of smoke and fire into unaffected zones. Failure to properly fire stop and seal penetrations through smoke and fire walls allows potential spread of smoke to other areas of the facility and endangers all staff, visitors and patients on the main level of the hospital. The facility census was 11.

Findings included:

1. Observation on 05/05/15 at 9:48 AM of the fire wall above the ceiling panels showed quarter-inch annular spaces around two one-inch diameter conduits that passed through the wall outside of room where medical gas cylinders were stored. In the same wall there was a six inch wide annular space above a bundle of communication cables that penetrated the wall above the fire doors.

2. Observation on 05/05/14 at 10:20 AM showed six holes in a fire wall of a barrier outside of the chapel:
- A one inch hole with nothing in it penetrated the both sides of the firewall.
- A one inch wide annular space around a three inch water pipe that penetrated the firewall.
- Four wire conduits that penetrated the wall had half-inch annular spaces around them.

3. Observation on 05/05/15 at 10:40 AM showed a quarter-inch annular space around a black sprinkler pipe, and multiple cables and wires that passed through an unsealed metal casing that measured four inches high by 12 inches wide.

4. During an interview on 05/05/15,at 10:40 AM Staff N, Plant Operations Manager, stated that maintenance did not regularly check above the ceilings and the last time anyone was up there was probably around 2011, when the construction was completed for the hospital expansion. He stated that he did not have a policy or preventive maintenance schedule for doing above-ceiling checks.

Based on observation and interview, the facility failed to ensure one of three sets of rated smoke/fire doors separating extended smoke compartments in a patient care area closed tightly in the door frame in accordance with 19.3.7. Failure of fire doors to close tightly in the door frame fails to inhibit the spread of smoke and endangers non-affected areas of the facility and potentially affects all staff, visitors and patients on the main level of the hospital. The facility census was 11.

Findings included:

1. Observation on 05/05/15 at 9:48 AM showed one of the two 1.5 hour rated fire doors stuck on the door frame and failed to close and separate the smoke compartment between the old part of the building and new (2011) part of the building. The set of fire doors was located next to a medical gas storage room in the central north-south corridor.

2. During an interview on 05/05/15 at 9:48 AM, Staff N, Plant Operations Manager, stated that he did not regularly check smoke and fire doors to see if they closed properly. He stated that he did not have a procedure or routine schedule for checking the doors.

Based on observation and interview, the facility failed to maintain three of seven smoke and fire barriers in accordance with 8.3 and 19.3.7.5 to ensure a minimum one half-hour fire resistance rating and prevent the spread of smoke and fire into unaffected zones. Failure to properly fire stop and seal penetrations through smoke and fire walls allows potential spread of smoke to other areas of the facility and endangers all staff, visitors and patients on the main level of the hospital. The facility census was 11.

Findings included:

1. Observation on 05/05/15 at 9:48 AM of the fire wall above the ceiling panels showed quarter-inch annular spaces around two one-inch diameter conduits that passed through the wall outside of room where medical gas cylinders were stored. In the same wall there was a six inch wide annular space above a bundle of communication cables that penetrated the wall above the fire doors.

2. Observation on 05/05/14 at 10:20 AM showed six holes in a fire wall of a barrier outside of the chapel:
- A one inch hole with nothing in it penetrated the both sides of the firewall.
- A one inch wide annular space around a three inch water pipe that penetrated the firewall.
- Four wire conduits that penetrated the wall had half-inch annular spaces around them.

3. Observation on 05/05/15 at 10:40 AM showed a quarter-inch annular space around a black sprinkler pipe, and multiple cables and wires that passed through an unsealed metal casing that measured four inches high by 12 inches wide.

4. During an interview on 05/05/15,at 10:40 AM Staff N, Plant Operations Manager, stated that maintenance did not regularly check above the ceilings and the last time anyone was up there was probably around 2011, when the construction was completed for the hospital expansion. He stated that he did not have a policy or preventive maintenance schedule for doing above-ceiling checks.

Based on observation and interview, the facility failed to ensure one of three sets of rated smoke/fire doors separating extended smoke compartments in a patient care area closed tightly in the door frame in accordance with 19.3.7. Failure of fire doors to close tightly in the door frame fails to inhibit the spread of smoke and endangers non-affected areas of the facility and potentially affects all staff, visitors and patients on the main level of the hospital. The facility census was 11.

Findings included:

1. Observation on 05/05/15 at 9:48 AM showed one of the two 1.5 hour rated fire doors stuck on the door frame and failed to close and separate the smoke compartment between the old part of the building and new (2011) part of the building. The set of fire doors was located next to a medical gas storage room in the central north-south corridor.

2. During an interview on 05/05/15 at 9:48 AM, Staff N, Plant Operations Manager, stated that he did not regularly check smoke and fire doors to see if they closed properly. He stated that he did not have a procedure or routine schedule for checking the doors.