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Based on observation and staff interview the facility failed to provide an occupancy separation wall that had all openings protected with a door closer to insure the two-hour rating was maintained in accordance to NFPA 101 Section 19.1.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in 1 of 4 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On May 5th, 2014 at 12:34 PM, it was observed that the door at the toilet for Blood Draw had a door closer installed but the arms were removed to allow the door to stay open at all times; this did not meet the Underwriter Laboratories (UL) Standards for a fire rated door within a fire rated barrier. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff E.

Based on observation and staff interviews, the facility failed to provide exit access corridor walls that were resistant to the passage of smoke in accordance to NFPA 101 Section 19.3.6.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in 1 of 4 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On May 5th, 2014 at 11:15 AM, it was observed that the paired doors into the exit corridor from the surgery suite were not smoke-tight (light was visible along the most of the vertical meeting edge of these paired leafs even with an astragal in place). This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff E.

Based on observation and staff interview, the facility failed to provide and maintain the one-half hour fire-rating and smoke tightness of the smoke barrier walls in accordance to NFPA 101 Section 19.3.7.3 as evidenced by the following item(s). This deficient practice could affect the patients in 1 of 4 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On May 5th, 2014 at 10:53 AM, it was observed that two armored (bx) cables were installed in the south face of the one-hour smoke compartment, above the paired doors into the west corridor of the patient wing, that were not fire caulked inside each of these cables. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff E.

Based on observation and staff interview, the facility failed to provide and maintain the one-hour rated enclosures with 45-minute rated doors into hazardous areas per NFPA 101 Section 19.3.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in 1 of 4 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On May 5th, 2014 at 11:27 AM, it was observed that in the north wall the Soiled Holding, of the OR Suite, a sprinkler pipe penetration was found that was not fire caulked to a one-hour fire rating. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff E.

Based on observation and staff interview, the facility failed to provide and maintain a sprinkler system that was installed in accordance to the Life Safety Code [ Sections 19.3.5.1 and 9.7.1.1 and NFPA 13 [1999 Ed.] Section 5.1.1. This deficient practice could affect the patients in 1 of 4 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On May 5th, 2014 at 1:09 PM, it was observed that a pendent sprinkler head was found within the alcove for the vending machines of the ED waiting room that was not provided with 18" clear space below the sprinkler deflector. This obstruction to the sprinkler discharge did not meet NFPA 13 (1999 Ed.) Section 5-6.5.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff E.

Based on observation and staff interview the facility failed to provide an occupancy separation wall that had all openings protected with a door closer to insure the two-hour rating was maintained in accordance to NFPA 101 Section 19.1.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in 1 of 4 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On May 5th, 2014 at 12:34 PM, it was observed that the door at the toilet for Blood Draw had a door closer installed but the arms were removed to allow the door to stay open at all times; this did not meet the Underwriter Laboratories (UL) Standards for a fire rated door within a fire rated barrier. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff E.

Based on observation and staff interviews, the facility failed to provide exit access corridor walls that were resistant to the passage of smoke in accordance to NFPA 101 Section 19.3.6.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in 1 of 4 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On May 5th, 2014 at 11:15 AM, it was observed that the paired doors into the exit corridor from the surgery suite were not smoke-tight (light was visible along the most of the vertical meeting edge of these paired leafs even with an astragal in place). This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff E.

Based on observation and staff interview, the facility failed to provide and maintain the one-half hour fire-rating and smoke tightness of the smoke barrier walls in accordance to NFPA 101 Section 19.3.7.3 as evidenced by the following item(s). This deficient practice could affect the patients in 1 of 4 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On May 5th, 2014 at 10:53 AM, it was observed that two armored (bx) cables were installed in the south face of the one-hour smoke compartment, above the paired doors into the west corridor of the patient wing, that were not fire caulked inside each of these cables. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff E.

Based on observation and staff interview, the facility failed to provide and maintain the one-hour rated enclosures with 45-minute rated doors into hazardous areas per NFPA 101 Section 19.3.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in 1 of 4 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On May 5th, 2014 at 11:27 AM, it was observed that in the north wall the Soiled Holding, of the OR Suite, a sprinkler pipe penetration was found that was not fire caulked to a one-hour fire rating. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff E.

Based on observation and staff interview, the facility failed to provide and maintain a sprinkler system that was installed in accordance to the Life Safety Code [ Sections 19.3.5.1 and 9.7.1.1 and NFPA 13 [1999 Ed.] Section 5.1.1. This deficient practice could affect the patients in 1 of 4 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On May 5th, 2014 at 1:09 PM, it was observed that a pendent sprinkler head was found within the alcove for the vending machines of the ED waiting room that was not provided with 18" clear space below the sprinkler deflector. This obstruction to the sprinkler discharge did not meet NFPA 13 (1999 Ed.) Section 5-6.5.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff E.