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Based on observation and interview, the facility failed to ensure doors in a required means of egress are not equipped with a latch or lock that requires the use of a tool or key from the egress side unless meeting the special locking arrangements for clinical needs in accordance with 19.2.2.2.5.1 and 19.2.2.2.6. This deficient practice could affect 4 out of 4 occupants in the event of a fire emergency.

Findings Include:
On July 21, 2025, at approximately 10:00 AM, observation revealed the facility has placed unapproved special locking devices on all egress doors located in the facility's lobby. A key card swipe pad was observed in place and needed to exit the facility. The lobby area is for business use only and not for patient care.

The Facility Maintenance Director and the Hospital Chief Operating Officer (COO) confirmed these findings during interview at the time of observation.

Based on observation and interview, the facility failed to provide hazardous areas protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 19.3.5.9. Doors shall be self-closing or automatic-closing. This deficient practice could affect 2 out of 4 occupants in the event of a fire emergency.

Findings Include:
On July 22, 2025, at approximately 10:00 AM, observation revealed the facility failed to install a required automatic closer on the storage closet #613. The closet will be used for combustible storage and is open to the patient hallway.

The Facility Maintenance Director and the Hospital Chief Operating Officer (COO) confirmed these findings during interview at the time of observation.

Based on observation and interview, the facility failed to ensure hospitals where required by construction type are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13. This deficient practice could affect 4 out of 4 occupants in the event of a fire emergency.

Findings Include:

On July 22, 2025, at approximately 12:30 PM observation revealed open grate ceiling tiles in the 4th floor pantry room 476. This will allow heat to bypass the wet fire suppression system sprinkler head. No sprinkler heads are installed above the open grate ceiling.

These findings were confirmed thorough interview with the maintenance director at the time of observation.