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Based on observation, testing, and interview, the provider failed to maintain proper separation of one of four hazardous areas (ambulance garage) in one randomly observed area (emergency department). Findings include:

1. Observation at 3:45 p.m. on 5/8/17 revealed the ninety-minute fire-rated doors separating the ambulance garage from the hospital emergency area were both not latched. The north leaf of the double-door would not positively latch. Testing of the north door leaf and interview with the maintenance supervisor at the time of the observation confirmed that finding. Doors to hazardous areas were required to be self-closing.

The deficiency affected one of several requirements regarding the separation of hazardous areas.

A. Based on observation, testing, and interview, the provider failed to maintain battery pack emergency lighting for two of two locations (basement generator and basement electrical rooms). Findings include:

1. Observation and testing beginning at 2:00 p.m. on 5/8/17 revealed the battery pack emergency light for the Caterpillar generator located in the basement did not work. The battery pack emergency light in the adjacent electrical room also did not work when tested. Interview with the maintenance supervisor at the time of the observations confirmed those findings.

The deficiency affected one of numerous requirements for the emergency lighting system.

B. Based on observation and interview, the provider failed to install a remote stop button for one of two generators (basement Caterpillar generator). Findings include:

1. Observation at 2:15 p.m. on 5/8/17 revealed there was not an emergency stop installed for the 125 kW Caterpillar diesel generator (located in the basement) in accordance with National Fire Protection Association (NFPA) 110 Section 5.6.5.6 (see attachment). Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The deficiency affected a single location required to be equipped with remote emergency stops.

Based on observation and interview, the provider failed to install exit signs for two of two exit locations in the basement in one of one basement room (boiler room-two exits). Findings include:

1. Observation at 2:30 a.m. on 5/8/17 revealed the basement boiler room was over 500 square feet in area and had three boilers with a total capacity in excess of five million British Thermal Units/hour (BTUH). The boiler room was required to have two exits with illuminated exit signs. Two remote exits were identified for the boiler room, but there were not any illuminated exit signs indicating the paths of egress.

Interview with the maintenance supervisor at the time of the observations confirmed those findings.

The deficiency affected one room required to be provided with marked and identifiable paths of egress.

Based on observation and interview, the provider failed to maintain proper separation of one of four hazardous areas (housekeeping storage) in one randomly observed area (dietary). Findings include:

1. Observation at 3:15 p.m. on 5/8/17 revealed the housekeeping storage room adjacent to the dietary area was over 100 square feet in area and contained combustible storage (paper goods). The door to the corridor was not equipped with a self-closing device. It was also not provided either with a one-hour fire-rated door or automatic fire sprinkler coverage (one or the other). Interview with the maintenance supervisor at the time of the observation confirmed those findings. Doors to hazardous areas were required to be self-closing.

The deficiency affected two of several requirements regarding the separation of hazardous areas.

Based on observation, testing, and interview, the provider failed to maintain positive latching for corridor doors in one randomly observed area (emergency department). Findings include:

1. Observation at 4:00 p.m. on 5/8/17 revealed the sliding door for the emergency department patient room would not latch into the frame when closed. The latch mechanism striker would not engage the strike plate on the door frame.
Further testing of the sliding door and interview with the maintenance supervisor at the time of the observation confirmed that finding.

The deficiency had the potential to affect 100% of the smoke compartment's occupants.