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Based on observation and interview, it was determined the facility failed to maintain corridor doors in two instance on one of four floors.

Findings include:

1. Observation on September 15, 2015, revealed the following:

a) At 9:02 a.m., patient room door 366 did not properly close in it's frame. There was a gap between the top of the door and the frame.
b) At 9:04 a.m., patient room door 364 did not properly close in it's frame. There was a gap between the top of the door and the frame.

Interview with the Facility Administrator and Maintenance Director on September 15, 2015, at 2:00 p.m., confirmed the corridor door issues.

Based on observation and interview, it was determined the facility failed to maintain vertical openings between floors in one instance on one of four floors.

Findings include:

1. Observation on September 14, 2015, revealed the following:

a) At 9:15 a.m., there were several vertical penetrations in the ceiling of basement room 0050.

Interview with the Facility Administrator and Maintenance Director on September 15, 2015, at 2:00 p.m., confirmed the vertical penetration issues.

Based on observation and interview, it was determined the facility failed to maintain smoke barriers in two instances on two of four floors.

Findings include:

1. Observation on September 14, 2015, revealed the following smoke barrier deficiencies:

a) At 9:32 a.m., the basement smoke barrier was incomplete.
b) At 12:45 p.m., inside of room 0218 on the second floor, the smoke barrier was incomplete.

Interview with the Facility Administrator and Maintenance Director on September 15, 2015, at 2:00 p.m., confirmed the smoke barrier deficiencies.

Based on observation and interview, it was determined the facility failed to maintain exit egress and access in one instance on one of four floors.

Findings include:

1. Observation on September 14, 2015, revealed the following:

a) At 9:21 a.m., there was storage in the corridor (furniture) blocking the exit.

Interview with the Facility Administrator and Maintenance Director on September 15, 2015, at 2:00 p.m., confirmed the exit access issues.

Based on observation and interview, it was determined that the facility failed to follow smoking regulations and facility policy in one instance throughout the facility.

Findings Include:

1. Observation on September 15, 2015, revealed the following smoking deficiency:

a) At 9:41 a.m., there was evidence of smoking (cigarette butts) outside by the loading and receiving area.

Interview with the Facility Administrator and Maintenance Director on September 15, 2015, at 2:00 p.m., confirmed the smoking issue.

Based on observation and interview, it was determined that the facility failed to comply with generator maintenance requirements in one instance throughout the facility.

Findings Include:

1. Observation on September 15, 2015, revealed the following generator deficiency:

a) At 12:35 p.m., during document review the facility lacked documentation indicating that the generator batteries specific gravity was being tested monthly.

Interview with the Facility Administrator and Maintenance Director on September 15, 2015, at 2:00 p.m., confirmed the generator issue.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring requirements in two instances on one of four floors.

Findings include:

1. Observation on September 15, 2015, revealed the following electrical wiring deficiencies:

a) At 9:05 a.m., in the third floor operating room nurse lounge there was a surge protector powering two coffee pots, a toaster, and a refrigerator.
b) At 9:07 a.m., in the third floor central supply there were two plug multipliers being used to charge medical equipment.

Interview with the Facility Administrator and Maintenance Director on September 15, 2015, at 2:00 p.m., confirmed the electrical wiring deficiencies.

Based on observation and interview, it was determined the facility failed to maintain corridor doors in two instance on one of four floors.

Findings include:

1. Observation on September 15, 2015, revealed the following:

a) At 9:02 a.m., patient room door 366 did not properly close in it's frame. There was a gap between the top of the door and the frame.
b) At 9:04 a.m., patient room door 364 did not properly close in it's frame. There was a gap between the top of the door and the frame.

Interview with the Facility Administrator and Maintenance Director on September 15, 2015, at 2:00 p.m., confirmed the corridor door issues.

Based on observation and interview, it was determined the facility failed to maintain vertical openings between floors in one instance on one of four floors.

Findings include:

1. Observation on September 14, 2015, revealed the following:

a) At 9:15 a.m., there were several vertical penetrations in the ceiling of basement room 0050.

Interview with the Facility Administrator and Maintenance Director on September 15, 2015, at 2:00 p.m., confirmed the vertical penetration issues.

Based on observation and interview, it was determined the facility failed to maintain smoke barriers in two instances on two of four floors.

Findings include:

1. Observation on September 14, 2015, revealed the following smoke barrier deficiencies:

a) At 9:32 a.m., the basement smoke barrier was incomplete.
b) At 12:45 p.m., inside of room 0218 on the second floor, the smoke barrier was incomplete.

Interview with the Facility Administrator and Maintenance Director on September 15, 2015, at 2:00 p.m., confirmed the smoke barrier deficiencies.

Based on observation and interview, it was determined the facility failed to maintain exit egress and access in one instance on one of four floors.

Findings include:

1. Observation on September 14, 2015, revealed the following:

a) At 9:21 a.m., there was storage in the corridor (furniture) blocking the exit.

Interview with the Facility Administrator and Maintenance Director on September 15, 2015, at 2:00 p.m., confirmed the exit access issues.

Based on observation and interview, it was determined that the facility failed to follow smoking regulations and facility policy in one instance throughout the facility.

Findings Include:

1. Observation on September 15, 2015, revealed the following smoking deficiency:

a) At 9:41 a.m., there was evidence of smoking (cigarette butts) outside by the loading and receiving area.

Interview with the Facility Administrator and Maintenance Director on September 15, 2015, at 2:00 p.m., confirmed the smoking issue.

Based on observation and interview, it was determined that the facility failed to comply with generator maintenance requirements in one instance throughout the facility.

Findings Include:

1. Observation on September 15, 2015, revealed the following generator deficiency:

a) At 12:35 p.m., during document review the facility lacked documentation indicating that the generator batteries specific gravity was being tested monthly.

Interview with the Facility Administrator and Maintenance Director on September 15, 2015, at 2:00 p.m., confirmed the generator issue.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring requirements in two instances on one of four floors.

Findings include:

1. Observation on September 15, 2015, revealed the following electrical wiring deficiencies:

a) At 9:05 a.m., in the third floor operating room nurse lounge there was a surge protector powering two coffee pots, a toaster, and a refrigerator.
b) At 9:07 a.m., in the third floor central supply there were two plug multipliers being used to charge medical equipment.

Interview with the Facility Administrator and Maintenance Director on September 15, 2015, at 2:00 p.m., confirmed the electrical wiring deficiencies.