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Based on observation and interview, the facility did not have a corridor door that meets the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the safety of the residents within the smoke compartment.

Findings include:
On facility tour between 10:30 AM and 05:00 PM on 09/08/2015, it was observed that the corridor door from the 1st floor Inpatient Pharmacy room to the corridor had 2 locking devices on the door which requires 2 motions to open the door.
This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain smoke barriers in accordance with the following requirements of 2000 NFPA 101, Section 19.3.7.3, and 8.3.4.1.

Findings include:

On facility tour between 10:30 AM and 5:00 PM on 09/08/15, observation revealed that the smoke barrier doors did not self close fully into the frame in the following areas:
1) 3rd floor smoke barrier doors between the nurse station and med/surg area.
2) 1st floor smoke barrier doors by ultrasound exam area.

This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and interview, the facility failed to provide protection of hazardous areas in accordance with the requirements of NFPA 101 -2000 edition, Section 19.3.2.1 and 8.4.1

Findings include:
On facility tour between 10:30 AM and 5:00 PM on 09/08/15, observation revealed that the 1st floor Storage Room door by the OR desk was damaged not allowing the door to self close and latch into the frame.

This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on review of reports, records and interview,, it was determined that the facility failed to conduct fire drills in accordance with NFPA 101 LSC (00) Section 19.7.1.2. This deficient practice could affect how staff react in the event of a fire.

Findings include:

On facility tour between 09:00 AM and 05:00 PM on 09/008/2015, based on review of available documentation it was reveled that the facility had no documentation for fire drills conducted on the night shift during the 2nd quarter of 2015. and 4th quarter of 2014.

This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and interview, the facility failed to install the sprinkler system in accordance with the requirements of NFPA 101 - 2000 edition, Sections 19.3.5 and 9.7: NFPA 13 - 1999 edition, Sections 5-1.1, 5-6.3.4, 5-6.5.2.3 and 5-13.8.1. The deficient practice could affect all residents, staff and visitors within the smoke compartment.

Findings include:
On facility tour between 09:00 AM and 05:00 PM on 09/08/2015, it was observed that the lower level Solarium Room did not have automatic fire sprinkler protection.

This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and interview, the facility has egress corridor obstructions which violates LSC 7.1.10. These obstructions could interfere with the convenient and effective removal of patients in an emergency situation.

Findings include:

On facility tour between 10:30 AM and 05:00 PM on 09/08/2015, observation revealed that the wall mounted writing stations do not automatically self close when tested in the following locations:
3rd floor located by rooms 301, 302, 314, 320, 321, 322, 323, 324, 325, 326, 328, 328.

This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and interview, the facility did not have a corridor door that meets the requirements of NFPA 101 LSC (00) Section 19.3.6.3.2. This deficient practice could affect the safety of the residents within the smoke compartment.

Findings include:
On facility tour between 10:30 AM and 05:00 PM on 09/08/2015, it was observed that the corridor door from the 1st floor Inpatient Pharmacy room to the corridor had 2 locking devices on the door which requires 2 motions to open the door.
This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain smoke barriers in accordance with the following requirements of 2000 NFPA 101, Section 19.3.7.3, and 8.3.4.1.

Findings include:

On facility tour between 10:30 AM and 5:00 PM on 09/08/15, observation revealed that the smoke barrier doors did not self close fully into the frame in the following areas:
1) 3rd floor smoke barrier doors between the nurse station and med/surg area.
2) 1st floor smoke barrier doors by ultrasound exam area.

This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and interview, the facility failed to provide protection of hazardous areas in accordance with the requirements of NFPA 101 -2000 edition, Section 19.3.2.1 and 8.4.1

Findings include:
On facility tour between 10:30 AM and 5:00 PM on 09/08/15, observation revealed that the 1st floor Storage Room door by the OR desk was damaged not allowing the door to self close and latch into the frame.

This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on review of reports, records and interview,, it was determined that the facility failed to conduct fire drills in accordance with NFPA 101 LSC (00) Section 19.7.1.2. This deficient practice could affect how staff react in the event of a fire.

Findings include:

On facility tour between 09:00 AM and 05:00 PM on 09/008/2015, based on review of available documentation it was reveled that the facility had no documentation for fire drills conducted on the night shift during the 2nd quarter of 2015. and 4th quarter of 2014.

This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and interview, the facility failed to install the sprinkler system in accordance with the requirements of NFPA 101 - 2000 edition, Sections 19.3.5 and 9.7: NFPA 13 - 1999 edition, Sections 5-1.1, 5-6.3.4, 5-6.5.2.3 and 5-13.8.1. The deficient practice could affect all residents, staff and visitors within the smoke compartment.

Findings include:
On facility tour between 09:00 AM and 05:00 PM on 09/08/2015, it was observed that the lower level Solarium Room did not have automatic fire sprinkler protection.

This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.

Based on observation and interview, the facility has egress corridor obstructions which violates LSC 7.1.10. These obstructions could interfere with the convenient and effective removal of patients in an emergency situation.

Findings include:

On facility tour between 10:30 AM and 05:00 PM on 09/08/2015, observation revealed that the wall mounted writing stations do not automatically self close when tested in the following locations:
3rd floor located by rooms 301, 302, 314, 320, 321, 322, 323, 324, 325, 326, 328, 328.

This deficient practice was confirmed by the Facilities Manager (TJ) at the time of discovery.