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Based upon observation and staff interview, the facility failed to ensure that the doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area were self-closing and kept in the closed position unless held open in accordance with 7.2.1.8.2 as required by 19.2.2.2.7 and 19.2.2.2.8. This deficient practice could potentially affect an isolated number of patients, staff and visitors at the time of an incident to be injured if the doors failed to operate as designed during a fire emergency.

Findings Include:

On 12/17/20 at approximately 11:04 am, by observation and interview of the Plant Operations Supervisor (POS) and Maintenance Tech (MT), the double doors in the corridor at the Boiler Room failed to properly closed when tested. This finding was verified with the POS and MT at the time of discovery.

Based upon observation and staff interview, the facility failed to ensure that the hazardous areas are protected by a fire barrier having a 1-Hour fire-resistance rating or protected by an automatic extinguishing system in accordance with 8.7.1 as required by 19.3.2.1 by failing to properly seal open penetrations in the rated walls of the Boiler Room. This deficient practice could potentially affect an isolated number of patients, staff and visitors at the time of an incident to be injured in a fire emergency.

Findings Include:

On 12/17/20 at approximately 11:04 am, by observation and interview of the POS and MT, penetrations of the rated wall in the Boiler Room failed to be properly sealed. This finding was verified with the POS and MT at the time of discovery.