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The facility failed to ensure the fire resistance rating of occupancy separation walls.

Observation determined:

1) The pair of cross-corridor doors through the two-hour fire resistant rated occupancy separation wall from the hospital to the clinic failed to self-close and latch.
2) The door through the two-hour fire resistant rated occupancy separation wall from Room B430 in the hospital to the business occupancy failed to self-close and latch.
3) The door through the two-hour fire resistant rated occupancy separation wall from Room B431 in the hospital to the business occupancy failed to self-close and latch.
4) The door through the two-hour fire resistant rated occupancy separation wall from Room B434 in the hospital to the business occupancy failed to self-close and latch.
5) The north pair of cross-corridor doors through the two-hour fire resistant rated occupancy separation wall from the hospital to the business occupancy failed to self-close and latch.
6) The south pair of cross-corridor doors through the two-hour fire resistant rated occupancy separation wall from the hospital to the business occupancy failed to self-close and latch.

Failure to ensure the fire resistance rating of occupancy separation walls as required increases the risk of death or injury due to fire.

This deficiency affected the entire facility.

In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. from an air supply diffuser or return air opening. 18.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1, A.17.7.4.1

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined:
1) The smoke detector in the OB Nurses Station was installed within 36 in. of a return air opening.
2) The smoke detector in the corridor by the elevator lobby on the first floor was installed within 36 in. of a return air opening.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected two (2) of numerous smoke detectors in the facility. The smoke detection system serves the entire facility.

The facility failed to ensure doors in smoke barrier walls were self-closing and resisted the passage of smoke. 18.3.7.8

Observation determined the west pair of cross-corridor doors in the first floor smoke barrier failed to self-close to the fully closed position and resist the passage of smoke.

Failure to ensure smoke barrier doors were self-closing and resisted the passage of smoke increases the risk of injury and death from fire.

This deficiency affected two (2) of four (4) smoke compartments.