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Based on observation, the facility failed to maintain the magnetic hold open devices for multiple sets of smoke doors and fire doors per the requirements of:

2012 NFPA 101, 19.2.2.2.7, and 7.2.1.8.2(4)

This deficiency affects 6 of 8 cross-corridor smoke/fire doors.

Findings include:

During a tour of the facility, the surveyor observed the magnetic hold open devices for 6 of the cross-corridor smoke/fire doors failed to release during loss of power to the fire alarm system. The two set of smoke cross-corridor smoke doors for the Psych.Unit did performed as designed.

A member of the maintenance staff was present when this deficiency was identified.

Based on observation, the facility failed to maintain the Operating Room smoke evacuation/WAGD system per the requirements of:

2012 NFPA 99, 5.1.3.7.7, and 5.1.3.8

This deficiency affects 2 of 2 Operating Rooms (OR).

Findings include:

During a tour of the facility, the surveyor could not verify that the smoke evacuation system or WAGD system continued to operate in OR's 1 and 2 after the activation of the fire alarm system using smoke aerosol on the smoke detector in OR 1.

A member of the maintenance staff was present when this deficiency was identified.

Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.5.4

This deficiency affects 1 of 1 outside oxygen cylinder storage area.

Findings include:

During a tour of the facility, the surveyor observed the oxygen cylinders in the outside oxygen cylinder storage area were not protected from continuous exposure to direct rays of the sun where extreme temperatures prevail.

A member of the maintenance staff was present when this deficiency was identified.