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Based on observation not all exit doors are installed or maintained to provide protection of the exit enclosure. This deficiency could affect patients, staff, and visitors if the exit access door did not provide the proper protection during a fire emergency.

Findings include:

On December 20, 2022, at 12:58pm while accompanied by the DSS it was observed that the door serving the upper level southwestern most stair failed to self-latch. This does not comply with the requirements of Table 8.3.4.2 and NFPA 80-2010, 6.4.1.1.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material and block exiting.

The findings are:

A. On December 20, 2022, at 12:30pm while accompanied by the DSS it was observed that the western most O.R on the southside of the upper level 1978 addition is used for storage and the door serving the room is not equipped with self-closing hardware. This condition does not comply with 19.3.2.1.3.

B. On December 20, 2022, at 12:35pm while accompanied by the DSS it was observed that the doors serving the sterile processing storage room on the upper level of the 1978 addition are propped open by wedges placed under the otherwise self-closing doors. This condition does not comply with 19.3.2.1.3.

C. On December 20, 2022, at 12:41pm while accompanied by the DSS it was observed that the room along the south corridor immediately west of the smoke barrier in the upper level 1978 addition is used for storage and the door serving the room is not equipped with self-closing hardware. This condition does not comply with 19.3.2.1.3.

D. On December 20, 2022, at 12:52pm while accompanied by the DSS it was observed that the southeastern most room of the upper level 1970 building is used for storage and the door serving the room is not equipped with self-closing hardware. This condition does not comply with 19.3.2.1.3.

E. On December 20, 2022, at 1:15pm while accompanied by the DSS it was observed that a storage room is connected to Trauma by a common ante room. The doors serving the common ante room are not equipped with self-closing hardware. This condition does not comply with 19.3.2.1.3.