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Based on observation and interview, the provider failed to maintain the two hour fire separation with ninety minute opening protection for one of two pairs of ninety minute doors. Findings include:

1. Observation at 10:15 a.m. on 3/9/16 revealed the double-doors separating the original 1960 hospital would not close and latch even when physical force was applied to the doors. Interview with the maintenance supervisor at the time of the observation confirmed the latching mechanism was loose and would not engage. He was unaware the latch was loose.

The deficiency would not affect any patients in the adjacent smoke compartment of the hospital. The deficiency could affect all of the current seven patients at the time of this survey of a possible of twenty-three patients if the maximum census were present.

Ref: 2000 NFPA 101 Section 19.1.1.4.1 and 19.1.1.4.2

Based on observation and document review, the provider failed to maintain a one hour fire resistive path of egress from the basement to the exterior of the building. One of two basement stairways (west) discharged onto the main level. Findings include:

1. Observation at 11:45 a.m. on 3/9/16 revealed the west basement stairway discharged onto the main level adjacent to the administration offices. A continuous one hour enclosure was not provided to the exterior of the building. Review of the previous life safety code survey confirmed that finding.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

The deficiency would not affect any patients with in the adjacent smoke compartment of the hospital. The deficiency could affect numerous administration staff within the affected smoke compartment.

Ref: 2000 NFPA 101 Section 19.3.1.1, 7.1.3.2, 8.2.5.2, and 8.2.5.4

Based on observation and interview, the provider failed to maintain two of two horizontal exit doors separating the original 1960 hospital form the 1996 emergency department addition. Findings include:

1. Observation at 11:00 a.m. on 3/9/16 revealed both sets of double-doors separating the original hospital for the fully sprinklered emergency department addition would not close and latch when allowed to operate with the door closer. Interview with the maintenance supervisor at the time of the observation confirmed both sets of double-doors were out of adjustment. He was unaware those doors would not latch.

The deficiency had the potential to affect three of the fourteen patient rooms located in the adjacent smoke compartment as well and numerous staff.

Ref: 2000 NFPA 101 Section 19.2.2.5, 7.2.4

Based on observation and interview, the provider failed to maintain two of two horizontal exit doors separating the original 1960 hospital from the 1996 emergency department addition. Findings include:

1. Observation at 11:00 a.m. on 3/9/16 revealed both sets of double-doors separating the original hospital for the fully sprinklered emergency department addition would not close and latch when allowed to operate with the door closer. Interview with the maintenance supervisor at the time of the observation confirmed both sets of double-doors were out of adjustment. He was unaware those doors would not latch.

The deficiency had the potential to affect three of the fourteen patient rooms located in the adjacent smoke compartment as well and numerous staff.

Ref: 2000 NFPA 101 Section 19.2.2.5, 7.2.4

Based on observation and interview, the provider failed to maintain the two hour fire separation with ninety minute opening protection for one of two pairs of ninety minute doors. Findings include:

1. Observation at 10:15 a.m. on 3/9/16 revealed the double-doors separating the original 1960 hospital would not close and latch even when physical force was applied to the doors. Interview with the maintenance supervisor at the time of the observation confirmed the latching mechanism was loose and would not engage. He was unaware the latch was loose.

The deficiency would not affect any patients in the adjacent smoke compartment of the hospital. The deficiency could affect all of the current seven patients at the time of this survey of a possible of twenty-three patients if the maximum census were present.

Ref: 2000 NFPA 101 Section 19.1.1.4.1 and 19.1.1.4.2

Based on observation and document review, the provider failed to maintain a one hour fire resistive path of egress from the basement to the exterior of the building. One of two basement stairways (west) discharged onto the main level. Findings include:

1. Observation at 11:45 a.m. on 3/9/16 revealed the west basement stairway discharged onto the main level adjacent to the administration offices. A continuous one hour enclosure was not provided to the exterior of the building. Review of the previous life safety code survey confirmed that finding.

The building meets the FSES. Please mark an "F" in the completion date column to indicate correction of the deficiencies identified in K000.

The deficiency would not affect any patients with in the adjacent smoke compartment of the hospital. The deficiency could affect numerous administration staff within the affected smoke compartment.

Ref: 2000 NFPA 101 Section 19.3.1.1, 7.1.3.2, 8.2.5.2, and 8.2.5.4

Based on observation and interview, the provider failed to maintain two of two horizontal exit doors separating the original 1960 hospital form the 1996 emergency department addition. Findings include:

1. Observation at 11:00 a.m. on 3/9/16 revealed both sets of double-doors separating the original hospital for the fully sprinklered emergency department addition would not close and latch when allowed to operate with the door closer. Interview with the maintenance supervisor at the time of the observation confirmed both sets of double-doors were out of adjustment. He was unaware those doors would not latch.

The deficiency had the potential to affect three of the fourteen patient rooms located in the adjacent smoke compartment as well and numerous staff.

Ref: 2000 NFPA 101 Section 19.2.2.5, 7.2.4

Based on observation and interview, the provider failed to maintain two of two horizontal exit doors separating the original 1960 hospital from the 1996 emergency department addition. Findings include:

1. Observation at 11:00 a.m. on 3/9/16 revealed both sets of double-doors separating the original hospital for the fully sprinklered emergency department addition would not close and latch when allowed to operate with the door closer. Interview with the maintenance supervisor at the time of the observation confirmed both sets of double-doors were out of adjustment. He was unaware those doors would not latch.

The deficiency had the potential to affect three of the fourteen patient rooms located in the adjacent smoke compartment as well and numerous staff.

Ref: 2000 NFPA 101 Section 19.2.2.5, 7.2.4