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Based on observation, the facility failed to maintain all corridor doors.

The findings included:

Observation during the initial tour on 3/31/15 at 9:38 AM revealed 1 of 2 doors to the radiology department control area failed to latch when closed.

This finding was verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 3/31/15.

Based on observation, the facility failed to protect all hazardous areas.

The findings included:

Observations during the initial tour on 3/31/15 beginning at 9:18 AM revealed the following:
a. The door to the 1st floor nurse dressing room/storage room did not have a closure on the door.
b. The door to the medical records room/file room on the 1st floor did not have a closure on the door and was not provided with a smoke detector.
c. The file storage room on the first floor did not have a smoke detector.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 3/31/15.

Based on observation and interview, the facility failed to provide and maintain emergency lighting.

The findings included:

Observations during the initial tour on 3/31/15 beginning at 9:00 AM revealed battery-powered emergency lights failed to test in the following areas:
a. Emergency department examination room #3.
b. Exit corridor of central supply.

An interview with the maintenance director on 3/31/15 at 9:49 AM revealed all exit discharge (exterior exits) lighting was not equipped with emergency power.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 3/31/15.

Based on observation, the facility failed to maintain all fire extinguishers.

The findings included:

Observations during the initial tour on 3/31/15 beginning at revealed the following fire extinguishers were overdue for their six year maintenance procedures:
a. The fire extinguisher by the exit near the 2nd floor central supply.
b. The fire extinguisher at 2nd floor radiology department break room.
c. The fire extinguisher at the 2nd floor radiology corridor.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 3/31/15.

Based on observation, the facility failed to maintain all fire dampers.

The findings included:

Observation during the initial tour on 3/31/15 at 9:22 AM revealed 1 of 2 fused link dampers in the telephone room at central supply was held open with a piece of wood instead of the required fused link.

This finding was verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 3/31/15.

NFPA 90A 1999 edition
3-4.5 Damper Closure.
3-4.5.1
All fire dampers and ceiling dampers shall close automatically, and they shall remain closed upon the operation of a listed fusible link or other approved heat-actuated device located where readily affected by an abnormal rise of temperature in the air duct.

Based on observation, the facility failed to maintain all exits.

The findings included:

Observations during the initial tour on 3/31/15 beginning at 9:40 AM revealed the following:
a. The exit door from the stairwell on the front of the building was rusted shut and had to be forced to open. A staff member was asked to open the door and was unable to do so.
b. The means of egress from the exit door from the stairwell on the front of the building was obstructed by limbs on a plant and in need of trimming.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 3/31/15.

Based on observation, the facility failed to prohibit penetrations through rated assemblies.

The findings included:

Observation of the first floor mechanical room during the initial tour on 3/31/15 beginning at 9:00 AM revealed the following:
a. The corridor wall had a penetration around the flexible conduit.
b. Four of 4 dampers in the 1st floor had drywall compound in the annular space around the dampers instead of the required caulking.
c. The ceiling had a penetration around the hot water line.
d. The ceiling had a penetration around the air conditioning vent.

NFPA 101 2000 edition 8.3.6.1

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 3/31/15.

Based on observation, it was determined the facility failed to maintain all electrical wiring and components.

The findings included:

Observations during the initial tour on 3/31/15 beginning at 9:05 AM revealed the following:
a. One of 3 receptacles in the emergency department waiting area had a broken cover.
b. An electrical cover was missing on the elevator.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 3/31/15.

Based on observation, the facility failed to maintain all corridor doors.

The findings included:

Observation during the initial tour on 3/31/15 at 9:38 AM revealed 1 of 2 doors to the radiology department control area failed to latch when closed.

This finding was verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 3/31/15.

Based on observation, the facility failed to protect all hazardous areas.

The findings included:

Observations during the initial tour on 3/31/15 beginning at 9:18 AM revealed the following:
a. The door to the 1st floor nurse dressing room/storage room did not have a closure on the door.
b. The door to the medical records room/file room on the 1st floor did not have a closure on the door and was not provided with a smoke detector.
c. The file storage room on the first floor did not have a smoke detector.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 3/31/15.

Based on observation and interview, the facility failed to provide and maintain emergency lighting.

The findings included:

Observations during the initial tour on 3/31/15 beginning at 9:00 AM revealed battery-powered emergency lights failed to test in the following areas:
a. Emergency department examination room #3.
b. Exit corridor of central supply.

An interview with the maintenance director on 3/31/15 at 9:49 AM revealed all exit discharge (exterior exits) lighting was not equipped with emergency power.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 3/31/15.

Based on observation, the facility failed to maintain all fire extinguishers.

The findings included:

Observations during the initial tour on 3/31/15 beginning at revealed the following fire extinguishers were overdue for their six year maintenance procedures:
a. The fire extinguisher by the exit near the 2nd floor central supply.
b. The fire extinguisher at 2nd floor radiology department break room.
c. The fire extinguisher at the 2nd floor radiology corridor.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 3/31/15.

Based on observation, the facility failed to maintain all fire dampers.

The findings included:

Observation during the initial tour on 3/31/15 at 9:22 AM revealed 1 of 2 fused link dampers in the telephone room at central supply was held open with a piece of wood instead of the required fused link.

This finding was verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 3/31/15.

NFPA 90A 1999 edition
3-4.5 Damper Closure.
3-4.5.1
All fire dampers and ceiling dampers shall close automatically, and they shall remain closed upon the operation of a listed fusible link or other approved heat-actuated device located where readily affected by an abnormal rise of temperature in the air duct.

Based on observation, the facility failed to maintain all exits.

The findings included:

Observations during the initial tour on 3/31/15 beginning at 9:40 AM revealed the following:
a. The exit door from the stairwell on the front of the building was rusted shut and had to be forced to open. A staff member was asked to open the door and was unable to do so.
b. The means of egress from the exit door from the stairwell on the front of the building was obstructed by limbs on a plant and in need of trimming.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 3/31/15.

Based on observation, the facility failed to prohibit penetrations through rated assemblies.

The findings included:

Observation of the first floor mechanical room during the initial tour on 3/31/15 beginning at 9:00 AM revealed the following:
a. The corridor wall had a penetration around the flexible conduit.
b. Four of 4 dampers in the 1st floor had drywall compound in the annular space around the dampers instead of the required caulking.
c. The ceiling had a penetration around the hot water line.
d. The ceiling had a penetration around the air conditioning vent.

NFPA 101 2000 edition 8.3.6.1

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 3/31/15.

Based on observation, it was determined the facility failed to maintain all electrical wiring and components.

The findings included:

Observations during the initial tour on 3/31/15 beginning at 9:05 AM revealed the following:
a. One of 3 receptacles in the emergency department waiting area had a broken cover.
b. An electrical cover was missing on the elevator.

These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 3/31/15.