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Based on observation and interview, the facility did not provide corridor separation doors with doors with positive-latching hardware, self-latching inactive doors, positive-latching hardware, smoke-tight seals at meeting edges, and doors that would close when pushed or pulled. This deficiency occurred in 3 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:


4. On 11/14/2012 at 11:30 am, observation revealed on the upper level floor in surgery, that the room had double corridor doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This deficiency occurred in 2 of the 9 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 11/12/2012 at 1:00 pm and on June 26, 2013 at 3 PM, observation revealed on the lower level floor in the dialysis equipment room, that penetration(s) were not sealed according to an approved method. The deficiency included 4 conduits above the ceiling, and 1 conduit at the ceiling line. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).
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Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with derangement signals at a continuously monitored location and did not provide a remote stop switch. This deficiency could affect all of the 9 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/12/2012 at 2:58 PM surveyors observed on the lower level floor in the maintenance shop, that audible and visual derangement signals were not located in a continuously monitored location of the maintenance personal. A generator anunciator panel was located in the main entrance (ER area). The observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.2(d) & NFPA 99 (1999 edition), 3-4.1.1.15(b). On June 26, 2013 the panel in the maintenance shop was in place, but the audible derangement signal was not working.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff I (Director of Facilities).