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Based on observation and interview, it was determined the facility failed to maintain the stairway enclosure fire rating in two instances, on two of three floors.

Findings include:

1. Observation on March 6, 2017, revealed the following stairway enclosure deficiencies:

a) 11:55 a.m., there was an open vent above the fire doors, in Wing 1 near the mail room, penetrating into the stairway.
b) 3:00 p.m., there was a conduit penetration into the stairway, above the stairway door in Wing 2 ASU, near the utility room.

Interview with the Director of Nursing and Quality and Director of Plant Operations on March 7, 2017, at 12:45 p.m., confirmed the stairway enclosure deficiencies.

Based on observation and interview, it was determined the facility failed to provide the required number of exits in two instances, on two of three floors.

Findings include:

1. Observation on March 6, 2017, revealed the following exiting issue:

a) 11:30 a.m., the second means of egress on the first floor of Wing 1, is through a non-compliant building.
b) 11:35 a.m., the second means of egress on the second floor of Wing 2 ASU, is through a non-compliant building.

Interview with the Director of Nursing and Quality and Director of Plant Operations on March 7, 2017, at 12:45 p.m., confirmed the 1st and 2nd floors lacked two approved exits.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, on one of three floors.

Findings include:

1. Observation on March 6, 2017, revealed the following automatic sprinkler system deficiency:

a) 11:42 a.m., there was electrical wiring attached to the sprinkler piping in the basement Electrical Room.
b) 12:52 p.m., there was a mix of standard response sprinkler heads and quick response sprinkler heads, in the Fluoro Room on the first floor.

Interview with the Director of Nursing and Quality and Director of Plant Operations on March 7, 2017, at 12:45 p.m., confirmed the automatic sprinkler system deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system throughout the facility.

Findings include:

1. Observation on March 7, 2017, at 10:00 a.m. revealed the pressure gauges at the fire pump were more than five years old. There was no documentation to support that the gauges had been replaced or recalibrated within the last five years.

Interview with the Director of Nursing and Quality and Director of Plant Operations on March 7, 2017, at 12:45 p.m., confirmed the sprinkler gauge deficiency.

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

Findings include:

1. Observation on March 7, 2017, revealed that patient room door 308 would not close and latch in its frame.

Interview with the Director of Nursing and Quality and Director of Plant Operations on March 7, 2017, at 12:45 p.m., confirmed the corridor door would not close and latch in the frame.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in two instances, affecting two of four smoke compartments.

Findings include:

1. Observation on March 7, 2017, at 10:10 a.m., revealed the doors to Gynecology Exam Rooms 4 and 5, which are smoke barrier doors, were not equipped with automatic closing devices.

Interview with the Director of Nursing and Quality and Director of Plant Operations on March 7, 2017, at 12:45 p.m., confirmed the smoke barrier doors lacked self-closures.

Based on observation and interview, it was determined the facility failed to maintain electrical receptacles in one instance, on one of three floors.

Findings include:

1. Observation on March 6, 2017, at 12:40 p.m., revealed a broken electrical receptacle on the first floor, near the pharmacy.

Interview with the Director of Nursing and Quality and Director of Plant Operations on March 7, 2017, at 12:45 p.m., confirmed the electrical receptacle was broken.