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Based on observations, the facility failed to properly protect corridors in accordance with NFPA 101 section 9.7, 19.3.6.1, 19.3.6.2, 19.3.6.4, and 19.3.6.5. The deficient practice affected all 16 compartments of the facility.

Findings Include:

On 3/24/16 at 11:45AM, observation revealed numerous open penetrations in the corridor walls located randomly throughout the building. The maintenance personnel were advised that we will do a full inspection of corridor walls upon revisit.

On 3/24/16 at 2:50 PM, observation revealed the Radiology Room was open to the main corridor of the facility and it requires to be protected by a smoke detector. The Radiology Room is part of the main corridor of the facility.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/25/16.

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 seven (7) of 16 compartments of the facility.

Findings Include:

On 3/24/16 at 11:45AM, observation revealed the following unprotected corridor doors/openings :

1) Door to Room 212 had an open penetration.

2) Coding Room door had roller latch.

3) Administrative Assistant door to DON ' s Office had roller latch.

4) Janitor ' s Room door near South Stairwell had locking door knob.

5) Activity Supply door had locking door knob.

6) Physical Therapy door had locking door knob.

7) X-ray 1 Room door lacks positive latching.

8) Door to Nurse Practitioner ' s Office had open penetrations.

9) Janitor Closet door has roller latch, slide bolt, and no positive latching.

10) Door to Room 211 had a Master lock.

11) The doors to Rooms 215, 217, and 219 had roller latches and lack automatic door closers.

12) Door to Exam Room 3 has roller latch.

13) Door to Exam Rooms 1 and 2 had roller latches and transfer grills.

14) Lab door in Surgery Clinic has no positive latching device.

15) Trauma Room door had roller latch

16) Office door near " Empty Area " has roller latch and was also observed this " Empty Area " was being used as a Surgery Suite.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/25/16.

Based on observations, the facility failed to protect vertical openings in accordance with NFPA 101 section 19.3.1.1. The deficient practice affected three (3) of 16 compartments of the facility.

Findings Include:

On 3/24/16 at 10:50 AM, observation revealed open penetrations in the following stairwell areas of the facility:

1) South stairwell

2) Electrical Room near Wound Care Clinic

3) Interior stairwell above ceiling

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/25/16.

K-21 Not Met

Based on observations, the facility failed to properly protect doors in vertical openings in accordance with NFPA 101 section 9.7, 19.2.2.2.6, 19.3.1.2, and 7.2.1.8.2. The deficient practice affected two (2) of 16 compartments of the facility.

Findings Include:

On 3/24/16 at 11:45AM, observation revealed the following vertical opening doors were deficient:

1) Fire Door near Room 147 did not close properly and completely

2) South Stairwell Fire Door did not close properly and completely

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/25/16.

Based on observations, the facility failed to provide a one half hour rating in accordance with NFPA 101 sections 8.3, 19.3.7.3, 19.3.7.5.The deficient practice affected nine (9) of 16 compartments of the facility.

Findings Include:

On 3/24/16 at 1:15 PM, observation revealed open penetrations in the following smoke barriers walls of the facility:

1) Smoke barrier wall in Medical Records Room

2) Above the smoke barrier doors near the Medical Records

3) Above the smoke barrier doors between the Kitchen and Dining Room

4) Above the smoke barrier doors between the Elevator and Elevator Equipment Room

5) Above the smoke barrier doors near Bedroom 148

6) Above the smoke barrier doors near Bedroom 223

7) Above the smoke barrier doors near the 2nd Floor Central Storage Room

8) Above the smoke barrier doors in the Primary Care Clinic Hallway

9) Above the smoke barrier doors near the Mammography Room

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/25/16.

Based on observations, the facility failed to protect hazardous areas in accordance with NFPA 101 section 8.4 and 19.3.2.1 The deficient practice affected six (6) of 16 compartments of the facility.

Findings Include:

On 3/24/16 at 11:25AM, observation revealed the following deficiencies of the hazardous areas of the facility:

1) Open penetrations in Storage Room near the I.T. Room and Elevator

2) Open penetration above the Laundry Room doors to the corridor

3) Open penetration above the Purchasing Room doors to the corridor

4) Open penetration above ceiling in brick wall separating the corridor and Office

5) Open penetration above the Storage Room across from X-Ray 2 Room

6) Medical Records Room door lacked automatic door closer

7) Diaper Room at South Nurses station lacked automatic door closer

8) Door of Biohazard Room at South Nurses station did not close properly

9) Medical Records Storage Room door did not close properly

10) Room 234 was being used as storage and the door lacked automatic door closer

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/25/16.

Based on document review, the facility failed to provide the required weekly and monthly generator testing in accordance with NFPA 99. The deficient practice affected all 16 compartments of the facility.

Findings Include:

While reviewing generator documentation on 3/24/16 at 2:00PM, the surveyor observed the facility could not provide neither the weekly inspection, monthly load nor annual records prior to September 15, 2015.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/25/16.

Based on observations, the facility failed to properly protect corridors in accordance with NFPA 101 section 9.7, 19.3.6.1, 19.3.6.2, 19.3.6.4, and 19.3.6.5. The deficient practice affected all 16 compartments of the facility.

Findings Include:

On 3/24/16 at 11:45AM, observation revealed numerous open penetrations in the corridor walls located randomly throughout the building. The maintenance personnel were advised that we will do a full inspection of corridor walls upon revisit.

On 3/24/16 at 2:50 PM, observation revealed the Radiology Room was open to the main corridor of the facility and it requires to be protected by a smoke detector. The Radiology Room is part of the main corridor of the facility.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/25/16.

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 seven (7) of 16 compartments of the facility.

Findings Include:

On 3/24/16 at 11:45AM, observation revealed the following unprotected corridor doors/openings :

1) Door to Room 212 had an open penetration.

2) Coding Room door had roller latch.

3) Administrative Assistant door to DON ' s Office had roller latch.

4) Janitor ' s Room door near South Stairwell had locking door knob.

5) Activity Supply door had locking door knob.

6) Physical Therapy door had locking door knob.

7) X-ray 1 Room door lacks positive latching.

8) Door to Nurse Practitioner ' s Office had open penetrations.

9) Janitor Closet door has roller latch, slide bolt, and no positive latching.

10) Door to Room 211 had a Master lock.

11) The doors to Rooms 215, 217, and 219 had roller latches and lack automatic door closers.

12) Door to Exam Room 3 has roller latch.

13) Door to Exam Rooms 1 and 2 had roller latches and transfer grills.

14) Lab door in Surgery Clinic has no positive latching device.

15) Trauma Room door had roller latch

16) Office door near " Empty Area " has roller latch and was also observed this " Empty Area " was being used as a Surgery Suite.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/25/16.

Based on observations, the facility failed to protect vertical openings in accordance with NFPA 101 section 19.3.1.1. The deficient practice affected three (3) of 16 compartments of the facility.

Findings Include:

On 3/24/16 at 10:50 AM, observation revealed open penetrations in the following stairwell areas of the facility:

1) South stairwell

2) Electrical Room near Wound Care Clinic

3) Interior stairwell above ceiling

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/25/16.

K-21 Not Met

Based on observations, the facility failed to properly protect doors in vertical openings in accordance with NFPA 101 section 9.7, 19.2.2.2.6, 19.3.1.2, and 7.2.1.8.2. The deficient practice affected two (2) of 16 compartments of the facility.

Findings Include:

On 3/24/16 at 11:45AM, observation revealed the following vertical opening doors were deficient:

1) Fire Door near Room 147 did not close properly and completely

2) South Stairwell Fire Door did not close properly and completely

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/25/16.

Based on observations, the facility failed to provide a one half hour rating in accordance with NFPA 101 sections 8.3, 19.3.7.3, 19.3.7.5.The deficient practice affected nine (9) of 16 compartments of the facility.

Findings Include:

On 3/24/16 at 1:15 PM, observation revealed open penetrations in the following smoke barriers walls of the facility:

1) Smoke barrier wall in Medical Records Room

2) Above the smoke barrier doors near the Medical Records

3) Above the smoke barrier doors between the Kitchen and Dining Room

4) Above the smoke barrier doors between the Elevator and Elevator Equipment Room

5) Above the smoke barrier doors near Bedroom 148

6) Above the smoke barrier doors near Bedroom 223

7) Above the smoke barrier doors near the 2nd Floor Central Storage Room

8) Above the smoke barrier doors in the Primary Care Clinic Hallway

9) Above the smoke barrier doors near the Mammography Room

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/25/16.

Based on observations, the facility failed to protect hazardous areas in accordance with NFPA 101 section 8.4 and 19.3.2.1 The deficient practice affected six (6) of 16 compartments of the facility.

Findings Include:

On 3/24/16 at 11:25AM, observation revealed the following deficiencies of the hazardous areas of the facility:

1) Open penetrations in Storage Room near the I.T. Room and Elevator

2) Open penetration above the Laundry Room doors to the corridor

3) Open penetration above the Purchasing Room doors to the corridor

4) Open penetration above ceiling in brick wall separating the corridor and Office

5) Open penetration above the Storage Room across from X-Ray 2 Room

6) Medical Records Room door lacked automatic door closer

7) Diaper Room at South Nurses station lacked automatic door closer

8) Door of Biohazard Room at South Nurses station did not close properly

9) Medical Records Storage Room door did not close properly

10) Room 234 was being used as storage and the door lacked automatic door closer

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/25/16.

Based on document review, the facility failed to provide the required weekly and monthly generator testing in accordance with NFPA 99. The deficient practice affected all 16 compartments of the facility.

Findings Include:

While reviewing generator documentation on 3/24/16 at 2:00PM, the surveyor observed the facility could not provide neither the weekly inspection, monthly load nor annual records prior to September 15, 2015.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 3/25/16.