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Based on observation and staff interview, the facility failed to separate hazardous areas with smoke resistive doors. This condition would allow smoke to migrate into the exit corridors.

Findings are:
Observation on 6/9/21, from 12:06 pm to 12:31 pm revealed:
1. The ER Soiled Utility room door did not positively latch when self-closed.
2. The Patient Wing Clean Utility room door did not positively latch when self-closed.
3. The Surgery Storage Room was separated from the exit corridor by a horizontal sliding door. The door did not self-close or positively latch.

In an interview on 6/9/21, from 12:06 pm to 12:31 pm, Maintenance A acknowledged the doors did not positively latch.

Based on observation and staff interview, the facility failed to install fire sprinklers so they would activate to suppress a fire. This condition would allow a fire to spread beyond the suppression capability of the system.

Findings are:
Observations on 6/9/21, from 11:43 am to 12:14 pm revealed:
1. The ceiling had been removed from the room behind the sterilizer. The pendant fire sprinkler measured 3 feet from the deck, to the deflector.
2. A cabinet was installed only 12 inches below the pendant fire sprinkler in Sterile Processing.
3. A fire sprinkler was not installed in the Allergy Mixing Room.

In an interview on 6/9/21, from 11:43 am to 12:14 pm, Maintenance A acknowledged the findings.

NFPA 13, 2010, 8.6.4 Deflector Position (Standard Pendent and Upright
Spray Sprinklers).
8.6.4.1 Distance Below Ceilings.
8.6.4.1.1 Unobstructed Construction.
8.6.4.1.1.1 Under unobstructed construction, the distance
between the sprinkler deflector and the ceiling shall be a minimum
of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm)
throughout the area of coverage of the sprinkler.
8.5.6* Clearance to Storage.
8.5.6.1* Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, or
8.5.6.5 are met, the clearance between the deflector and the
top of storage shall be 18 in. (457 mm) or greater.

4.1 Level of Protection. A building, where protected by an
automatic sprinkler system installation, shall be provided with
sprinklers in all areas except where specific sections of this
standard permit the omission of sprinklers.