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Based on observations, the facility failed to provide the safety requirements for area open to the main corridor of the facility in accordance with 19.3.6.1 (7). This deficient practice has the potential of affecting one (1) of three (3) smoke compartments in the facility on the day of survey.

Findings Include:

On 5-23-17 at 11:25 AM, observation revealed the Pharmacy was open to the main corridor of the facility and were not electrically supervised by an automatic detection system (hard wired smoke detector).

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview.

Based on observations, the facility failed to properly protect corridor openings, in accordance with NFPA 101 section 19.3.6.3. The deficient practice affected one (1) of three (3) smoke compartments on the day of the survey.

Findings Include:

On 5-23-17 at 11:45 AM, observation revealed the following corridor door deficiencies in the facility:

1) Radiology Door has lock higher than 48 inches from the floor
2) X-Ray #1 door has no positive latching
3) Isolation Storage Room door near Pharmacy has no positive latching
4) Acute Care Room 105 has a keyed lock from both sides
5) Pharmacy Dutch-door could not resist the passage of smoke

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview.

Based on observations and testing, the facility failed to provide the generator in accordance with NFPA 99. The deficient practice affected three (3) of three (3) smoke compartments in the facility on the day of the survey.

Findings Include:

On 5-23-17 at 12:35 PM, observation revealed the generator to transferred power to the facility in 92 seconds. The generator is required to transfer power to the facility within 10 seconds after losing power to the building.

The administrator and the maintenance director were notified during the survey as well as the exit conference.