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Based on observation and interview, the facility failed to maintain the ratings of its smoke and/or fire barriers, failed to have doors resist the passage of smoke into the corridor, failed to protect all structural steel, failed to ensure each door in a smoke barrier closed, failed to ensure exit accesses were readily available, failed to ensure emergency lighting was tested, failed to ensure fire drills were conducted properly, failed to ensure smoke detectors were mounted and tested properly, failed to ensure sprinkler system was maintained properly, failed to ensure fire watch policies were documented properly, and failed to ensure each patient care suite was 10,000 square feet or less in area. This has the potential to affect all patients, staff, and visitors to the facility. The facility's capacity is 225 beds, and the census was 216 patients.

Findings include:

See A709.

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients, staff, and visitors to the facility. The facility ' s capacity is 225 beds, and the census was 216 patients.

Findings include:

K12 Unprotected structural steel
K18 Failed to have doors protect corridor openings from smoke
K20 Each stairway door had a protective rating of at least two hours
K25 Failed to maintain the ratings of its fire and/or smoke barriers
K27 Failed to ensure each door in a smoke barrier closed
K38 Failed to ensure each exit access was readily accessible
K46 Emergency lighting not tested in accordance with NFPA 101 7.9, 2000 edition
K50 Fire drills not held under varying conditions on the third shift
K52 Smoke detectors not at least three feet from air vents
K54 Lacked documentation of smoke detector sensitivity
K62 Failed to maintain an automatic sprinkler system in accordance with NFPA 25.
K114 Rating of barrier between main hospital and ambulatory surgery center not maintained
K130 Operating room suite size greater than 10,000 square feet
K130 Intensive care unit and cardiovascular unit suites greater than 5,000 square feet.
K154 Fire watch policy for sprinkler system with exceptions
K155 Fire watch policy for alarm system with exceptions.