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Based on observation and interview, the facility failed to maintain corridor doors in accordance with NFPA 101(2012 edition) Sections 19.3.6.3. These deficient practices could affect an undetermined number of patients, staff and visitors.

Findings include:

1. On 09/21/2021 at 10:15 am, observation revealed that the corridor door at the bio-hazard room did not positively latch. The fixed leaf of the double door included a manual flush bolt at the top of the door. The bottom flush bolt mechanism was not operational. This is door 1054B of the facility plans.

2. On 09/21/2021 at 11:40 am, observation revealed that the corridor door at the radiology waiting room did not positively latch. The fixed leaf of the double door included a manual flush bolt at the top and bottom of the inoperable leaf. This is door 1425A of the facility plans.

These deficient practices were confirmed by Staff M and V at the time of discovery.

Based on record review and interview, the facility failed to test electrical receptacles in accordance with the requirements of NFPA 99 - 2012 edition, Section 6.3.3.2, 6.3.3.2.1, 6.3.3.2.2, 6.3.3.2.3, 6.3.3.2.4 and 6.3.4. This deficient practice could affect an undedtermined number of patients, staff and visitors.

Findings include:

On 09/21/2021 at 1:09 pm, record review revealed that there were hospital grade outlets located in the patient care areas. Interview with Staff L and O revealed that the facility had no documentation of the continuity of ground in circuit, polarity or retention testing of the electrical outlets when they were initially installed or any record of testing since.

This finding was confirmed by Staff L and O at the time of discovery.