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Based on visual observation the facility failed to provide doors in corridor openings that are 1 3/4 solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors shall be provided with means suitaable for keeping the door closed.

Findings:

During the facility tour, between the hours of 10:00 and 11:30 it was observed
1/Storage cart room door is not closing and latching in its frame.
2/Both corridor doors leading to dietary do not have any positive laching on these doors.
3/Employee break room door does not have any positive latching .
4/Employee locker room door does not have any positive latching.

Interview with Maintenance Supervisor revealed the facility was not aware these doors were either not latching or did not have the required positive latching.

Based on visual observation the facility failed to provide smoke barriers that are constructed to provide at least a one half hour resistance rating and constructed in accordance with 8.3.

Findings:

During the facility tour, between the hours of 10:00 and 11:30 it was observed that the smoke barrier wall over corridor doors at Morgue entrance have wires that need to be sealed with caulk.

Interview with Maintenance Supervisor revealed the facility was not aware that the smoke barrier wall had unsealed wires.

Based on visual observation the facility failed to provide one hour rated construction (with 3/4 hour fire-rated doors) or an approved fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. Doors shall be self-closing.

Findings:

During the facility tour, between the hours of 10:00 and 11:30 it was observed
1/Soiled linen door to laundry area not closing and latching in its frame.
2/Biohazard door needs door closure.
3/Room 5 supply room door not closing and latching in its frame.

Interview with Maintenance Supervisor revealed the facility was not aware these hazardous area doors were not closing and latching in their frames, or did not have door closure.

Based on visual observation the facility failed to provide Cooking facility that was in accordance with 9.2.3,18.3.2.6, 19.3.2.6, and NFPA 96.

Findings:

During the record review and facility tour, between the hours of 10:00 and 11:30 it was observed the hood system protecting the gas stove in kitchen was yellow-tagged. This system was deemed out-dated and is in the process of being replaced.

Interview with Maintenance Supervisor revealed the facility is in the process of having the system replaced in order to have a system in accordance with regulations of NFPA 96 and to be green-tagged.

Based on visual observation the facility failed to provide medical gas storage areas with precautionary signage, that is conspicuously displayed on each door of the storage room or enclosure. The signage shall include the following wording as a minimum: Cauction, Oxidizing Gas(es) stored within, No Smoking.

Findings:

During the facility tour, between the hours of 10:00 and 11:30 it was observed that the oxygen storage closet that is located in the medical records storage corridor does not have the proper signage on door.

Interview with the Maintenance Supervisor revealed the facility was not aware that this signage on door was needed.

Based on visual observation the facility failed to provide Generators inspected weekly and excercised under load for 30 minutes per month and shall be in accordance with NFPA 99 and NFPA 110.

Findings:

During the record review and facility tour, between the hours of 10:00 and 11:30 it was observed that the documentation is not showing when generator is being excercised under full load for 30 minutes per month.

Interview the Maintenance Supervisor revealed the facility was not aware that the documentation for the monthly full load 30 minute testing was not being recorded.

Based on visual observation the facility failed to provide doors in corridor openings that are 1 3/4 solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors shall be provided with means suitaable for keeping the door closed.

Findings:

During the facility tour, between the hours of 10:00 and 11:30 it was observed
1/Storage cart room door is not closing and latching in its frame.
2/Both corridor doors leading to dietary do not have any positive laching on these doors.
3/Employee break room door does not have any positive latching .
4/Employee locker room door does not have any positive latching.

Interview with Maintenance Supervisor revealed the facility was not aware these doors were either not latching or did not have the required positive latching.

Based on visual observation the facility failed to provide smoke barriers that are constructed to provide at least a one half hour resistance rating and constructed in accordance with 8.3.

Findings:

During the facility tour, between the hours of 10:00 and 11:30 it was observed that the smoke barrier wall over corridor doors at Morgue entrance have wires that need to be sealed with caulk.

Interview with Maintenance Supervisor revealed the facility was not aware that the smoke barrier wall had unsealed wires.

Based on visual observation the facility failed to provide one hour rated construction (with 3/4 hour fire-rated doors) or an approved fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. Doors shall be self-closing.

Findings:

During the facility tour, between the hours of 10:00 and 11:30 it was observed
1/Soiled linen door to laundry area not closing and latching in its frame.
2/Biohazard door needs door closure.
3/Room 5 supply room door not closing and latching in its frame.

Interview with Maintenance Supervisor revealed the facility was not aware these hazardous area doors were not closing and latching in their frames, or did not have door closure.

Based on visual observation the facility failed to provide Cooking facility that was in accordance with 9.2.3,18.3.2.6, 19.3.2.6, and NFPA 96.

Findings:

During the record review and facility tour, between the hours of 10:00 and 11:30 it was observed the hood system protecting the gas stove in kitchen was yellow-tagged. This system was deemed out-dated and is in the process of being replaced.

Interview with Maintenance Supervisor revealed the facility is in the process of having the system replaced in order to have a system in accordance with regulations of NFPA 96 and to be green-tagged.

Based on visual observation the facility failed to provide medical gas storage areas with precautionary signage, that is conspicuously displayed on each door of the storage room or enclosure. The signage shall include the following wording as a minimum: Cauction, Oxidizing Gas(es) stored within, No Smoking.

Findings:

During the facility tour, between the hours of 10:00 and 11:30 it was observed that the oxygen storage closet that is located in the medical records storage corridor does not have the proper signage on door.

Interview with the Maintenance Supervisor revealed the facility was not aware that this signage on door was needed.

Based on visual observation the facility failed to provide Generators inspected weekly and excercised under load for 30 minutes per month and shall be in accordance with NFPA 99 and NFPA 110.

Findings:

During the record review and facility tour, between the hours of 10:00 and 11:30 it was observed that the documentation is not showing when generator is being excercised under full load for 30 minutes per month.

Interview the Maintenance Supervisor revealed the facility was not aware that the documentation for the monthly full load 30 minute testing was not being recorded.