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Based upon observation and staff interview, the facility failed to ensure that 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 all patients, staff and visitors in the vicinity at the time of an incident resulting in injury if the doors failed to operate as designed during a fire emergency.

Findings Include:

On 7/23/19 at approximately 10:59 am, by observation of the double doors between long and short term Cath Lab on 2 North failed to properly close and latch when tested. This finding was verified with the Director Corporate Facilities & Energy (DFE) at the time of discovery.

On 7/23/19 at approximately 11:04 am, observation of the double doors by Cardiac Holding room #20 on 2 North failed to properly close and latch when tested. This finding was verified with the DFE at the time of discovery.

On 7/23/19 at approximately 11:22 am, by observation of the storage room door by Ultrasound on 2 North failed to properly close and latch when tested. This finding was verified with the DFE at the time of discovery.

On 7/23/19 at approximately 10:48 am, observation of the Utility Room in Pre-Op on 3 Central failed to properly close and latch when tested. This finding was verified with the Manager of Engineering Services (MES) at the time of discovery.


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On 7/23/19 at approximately 1:29 pm, observation of the door on the Intensive Care Unit Ante Room failed to properly close and latch when tested. This finding was verified with the Director of Engineering Services (DES) at the time of discovery.

Based upon observation and staff interview, the facility failed to ensure that 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. This deficient practice could potentially affect all patients, staff and visitors at the time of an incident to be injured in a fire emergency.

Findings Include:
On 7/23/19 at approximately 10:52 am observation of penetrations of the smoke barrier wall at the Prep/Recovery Room #1 failed to be properly sealed. This finding was verified with the Manager of Engineering Services (MES) at the time of discovery.

Based upon observation and interview, the facility failed to ensure that automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 and records are readily available as required by 9.7.5, 9.7.7, 9.7.8, and NFPA 25. This deficient practice could potentially affect all patients, staff and visitors at the time of an incident to be injured if the facilities fire suppression system fails to operate as designed during a fire emergency.

Findings Include:
On 7/23/19 at approximately 10:42 am observed combustible storage was too close to sprinkler heads in the Rehab Living Center storage closet on 4 North. This finding was verified with the Director Corporate Facilities & Energy (DFE) at the time of discovery.

On 7/23/19 at approximately 1:09 pm observed combustible storage was too close to sprinkler heads in the Conference Room by the Emergency Department storage room on 2 North. This finding was verified with the DFE at the time of discovery.

On 7/23/19 at approximately 1:32 pm observed there was a missing sprinkler head escutcheon at the South Elevators in the elevator lobby on 2 North. This finding was verified with the DFE at the time of discovery.



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On 7/23/19 at approximately 10:34 am observed in the Housekeeping Closet on 11 South there was a Lab Chemical Feed Hose wrapped around a sprinkler pipe. This finding was verified with the Director of Engineering Services (DES) at the time of discovery.

On 7/23/19 at approximately 10:58 am observed in the Housekeeping Closet on 10 South there was a Lab Chemical Feed Hose wrapped around a sprinkler pipe. This finding was verified with the DES at the time of discovery.

Based upon observation and staff interview, the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, resist the passage of smoke, equipped with a means suitable for keeping the door closed, and there is no impediment to the closing of doors as required by 19.3.6.3 and 42 CFR 403, 418, 460, 482, 483, and 485. This deficient practice could potentially affect all patients, staff and visitors at the time of an incident to be injured if the door fails during a fire emergency.

Findings Include:
On 7/23/19 at approximately 1:25 pm observed the Emergency Room storage room door by CT Scan had a hole penetrating the door. This finding was verified with the Director Corporate Facilities & Energy (DFE) at the time of discovery.