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Based on observation, the facility failed to provide doors with a suitable means of latching for 2 corridor doors on 2 floors. This could potentially affect patients, family members and staff in the event of a smoke or fire emergency.

Findings:1) During a tour of the facility on 8/19/10 between 7:30am and 11:30am, the 4th floor Rehab Treatment room was observed to not positive latch in the frame but had only a dead bolt on the door.

2) During tour of the facility on 8/19/10 between 7:30am and 11;30am, the Equipment Room next to Labor and Delivery Waiting room was observed to not positive latch in the frame but had only a deadbolt on the door.

Baseed on observation, the facility failed to provide stairways between floors that are enclosed with construction having a fire resistive rating of at least one hour for 9 stairwell doors in the facility potentially affecting 229 of 229 patients in the facility in the event of a smoke or fire emergency.

Findings: During tour of the facility on 8/18/10 between 7:30am and 5:30pm, the following stairwell doors could not be determined to have the proper fire rating on them:

A) The two Penthouse stairwell doors had no fire label affixed to it.
B) The stairwell door across from 6103 had no fire label affixed to it.
C) The stairwell 2 stairwell door on the 5th floor had a fire rated label of 45 minutes affixed to it.
D) The stairwell door across from 2103 had no fire rated label affixed to it.
E) The stairwell door by 2nd floor horizontal exit had no label affixed to it.
F) The rear stairwell exits from Intensive Care Unit and Cardiac Care Unit were observed to have 45 minute fire labels affixed to them.

Based on observation, the facility failed to provide smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3 for 3 smoke barriers on one floor of the facility. This could potentially affect all patients, staff and visitors in the surgery and waiting room areas of the facility in the event of a smoke or fire emergency.

Findings: During tour of the facility on 8/19/10 between 7:30am, and 4:00pm, the following smoke barriers were observed to have deficiencies:

A) The smoke barrier wall inside recovery at 2nd floor surgery area was observed to have three 4 inch x 4 inch unsealed holes in the wall above the ceiling.

B) The smoke barrier in the corridor outside of recovery there were five 1 inch conduits unsealed above the ceiling.

C) The smoke barrier of the Specialty Procedure equipment holding there were two 3 inch x 2 inch unsealed holes above the ceiling.

Based on observation, the facility failed to provide door openings in smoke barriers that are self closing in accordance with 19.2.2.2.6 for 2 sets of smoke barrier doors in the facility. This could potentially affecy 229 of 229 patients in the facility in the event of a smoke or fire emergency.

Findings: During tour of the facility on 8/19/10 at 10:00am, the door coordinators of the smoke barrier walls going into the kitchen and going into case management was observed to not function correctly on test. On test, the door coordinators failed to allow the double doors to close smoke tight in the frame.

Based on observation, the facility failed to provide a fire alarm system that is maintained in accordance with NFPA 72 for 2 smoke compartments in the facility. This could potentially affect 3 patients in the facility in the event of a smoke or fire emergency.

Findings: During a test of the fire alarm system on 8/1910 between 8:00am and 11:30am, the following deficiencies were observed:

A) The horn/strobe devices in the Neurovascular Stroke Unit was observed to not function on test.

B) The Strobes in the Kitchen area were observed to flash only every 10 seconds during test.

Based on observation, the facility failed to provide air conditioning ducts penetrating smoke barriers that are protected in accordance with 8.3.6 for 1 smoke barrier wall in the surgery area. This could potentially affect all patients in the surgery area in the event of a smoke or fire emergency.

Findings: During tour of the facility on 8/19/10 between 7:30am, and 4:00pm, the smoke barrier in the dirty equipment area of surgery was observed to have a flex air conditioning duct penetrating the smoke barrier wall that had no smoke damper installed in it.