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Based on observations and interview, it was determined the facility failed to ensure one door, protecting a hazardous area, was equipped with an automatic door closing device.

Findings include:

Observations during tour on 2/16/23 between 11:00 a.m. and 12:00 p.m. with Staff A (Facility Director) and Staff B (Facility Assistant Staff) revealed the Sim's Lab, located on the lower level of the Medical Office Building, labeled B 504, is being used to store large quantities of combustible materials and exceeds 200 square feet (approximately). The door panel failed to be equipped with an automatic door closing device.

Interview on 2/16/23 with Staff A and Staff B confirmed the above findings, location, and existing conditions.

NFPA 101 LIFE SAFETY CODE (2012 edition)
7.2.9.4 Emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110 STANDARD for EMERGENCY and STANDBY POWER SYSTEMS (2010 edition).
7.9.3.1.1 Testing of the emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the AHJ (Authority Having Jurisdiction).
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3).

Based on observations and interview, it was determined the facility failed to ensure four battery powered emergency lighting units could operate when the testing button was activated.

Findings include:

Observations during tour on 2/16/23 between 10:30 a.m. and 11:00 a.m. with Staff A (Facility Director) and Staff B (Assistant Facility Staff) revealed in the lower level of the Medical Office Building, Urology Department, Rooms 1620 and 1617, each had two battery powered emergency lighting units which failed to operate when the testing button was fully depressed.

Interview on 2/16/23 with Staff A and Staff B confirmed the above findings, locations, and existing conditions.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems

5.2 Inspection
5.2..1 Sprinklers
5.2.1.1 Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation.
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5) Loading
(6) Painting unless painted by the sprinkler manufacturer

Based on observations and interview, it was determined that the facility failed to ensure sprinkler heads are not loaded with lint, dust, and debris.

Findings include:

Observations during tour on 2/15/23 and 2/16/23 with Staff A (Facility Director) and Staff B (Facility Assistant Staff) revealed multiple loaded sprinkler heads on a facility wide basis. The sprinkler heads have a heavy coat of lint, dust and/or debris that blocks the color of the bulb or stamped related information of the sprinkler head characteristics. The majority of the loaded sprinkler heads are within 42 inches of a ceiling mounted air supply register.

The observed areas with loaded heads are mixed locations throughout the facility.

Some of the identified areas are as follows:

(Main Hospital)
1. The Emergency Department has multiple loaded heads throughout the corridors.
2. The main cafeteria has multiple loaded heads.
3. The Administration Suite has multiple loaded heads.
4. The Occupational Therapy room (#5) has multiple loaded heads.
5. The Operating Suite corridor has at least 3 loaded heads.

(Medical Office Building)
1. The Quality Improvement Department has multiple loaded heads,
2. The lower level conference room and multiple office locations have loaded heads.
3. The Urology Department has multiple loaded heads in the corridors.

Interview on 2/15/23 and 2/16 23 with Staff A and Staff B confirmed the above findings, locations, and existing conditions throughout the entire facility at random locations.

NFPA 101 Life Safety Code (2012 edition)
8.5 Smoke Barriers
8.5.2.1 Smoke barriers required by this code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof.
8.5.2.2 Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Based on observations and interview, it was determined the facility failed to ensure smoke barriers are maintained to resist the passage of smoke and effects from fire.

Findings include:

Observations during tour on 2/16/23 between 12:30 p.m. and 2:30 p.m. with Staff A (Facility Director) and Staff B (Facility Assistant Staff) revealed at least eight smoke/fire barrier locations which had unprotected penetrations through the barrier walls.

All of the observed unprotected barrier penetrations were located above the suspended ceiling tiles in their respective locations.

These six locations and conditions are as follows:

1. Above the double fire door assembly M0100, in the main connecting stairwell between the Medical Office Building (MOB) and the main hospital, has two unsealed cable wire penetrations.

2. To the left of the double fire door assembly M0100, in the main connecting stairwell between the MOB and the main hospital, has three open penetrations with the original penetrating items removed.

3. Above the smoke barrier door assembly IN004 has two unsealed metal conduits penetrating the smoke barrier.

4. In the IT department, above the smoke barrier door assembly 0B100A has two unprotected alarm wires penetrating the smoke barrier.

5. Above the smoke barrier door assembly PC160 has an unprotected 4 inches open ended conduit penetrating the smoke barrier wall.

6 Above the door assembly AD142 (patient aces) has an unprotected 2 inches open ended conduit penetrating the smoke resistant wall assembly.

Interview on 2/16/23 with Staff A and Staff B confirmed the above findings, locations, and existing conditions.