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Based on observation, the facility failed to maintain the magnetic hold open devices for the smoke and fire doors per the requirements of:

2012 NFPA 101, 19.2.2.2.7, and 7.2.1.8.2(4)

This deficiency affects all cross-corridor smoke and fire doors.

Findings include:

During a tour of the facility, the surveyor observed the magnetic hold open devices for all pairs of the cross-corridor smoke and fire doors, failed to release during loss of power to the fire alarm system.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain a horizontal exit per the requirements of:

2012 NFPA 101, 19.2.2.5, 7.2.4.3.1, and 8.3.5.1

This deficiency affects two of the three 2-hour fire barriers.

Findings include:

During a tour of the facility, the surveyor observed unsealed penetrations above the ceiling in the following 2-hour fire barriers:

1. A 3/4" EMT conduit used as a chase for one black cable over the door between C.T. Hall and Therapy

2. Multiple gray and blue cables over the door between X-Ray Hall and Data Room 2

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the fire alarm system per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, Table 14.3.1(9)(h)

This deficiency affects all smoke detectors.

Findings include:

During a tour of the facility, the facility failed to provide documentation of conducting semi-annual visual inspections on the smoke detectors within the past 12 months.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to install quick-response sprinklers per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.1.1(1)
2010 NFPA 13, 8.3.3.2, and 8.3.3.4

This deficiency affects 1 of 6 smoke compartment.

Findings include:

During a tour of the facility, the surveyor observed a quick-response sprinkler head installed in the same compartment (the 1981 addition corridor, patient rooms 118-122) with standard-response sprinkler heads.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and review of documentation, the facility failed to maintain the automatic sprinklers per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.5
2011 NFPA 25, 5.3.1.1.1.6

This deficiency affects 2 of 2 dry sprinklers.

Findings include:

During a tour of the facility, the facility failed to provide documentation that the 2013 side-wall dry sprinklers, located on the outside over the old smoking area (east end of hospital outside of the 1981 addition) had been replaced or a representative sample tested within 10 years of installation.

A member of the maintenance staff and the administrator were present when this deficiency was identified.

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Based on observation, the facility failed to maintain a corridor door per the requirements of:

2012 NFPA 101, 19.3.6.3.4

This deficiency affects 1 corridor door.

Findings include:

During a tour of the facility, the surveyor observed the Case Managers Office corridor door had an undercut of 1 1/4" gap between the floor and bottom of the door; prohibiting the door from being smoke resistive.

A member of the maintenance staff was present when this deficiency was identified.