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Based on observation and staff interview, the facility did not ensure that doors in a required means of egress are installed in accordance with the requirements of NFPA 101 (2012 edition), 19.2.1 and 7.2.1.7.3. This deficient practice could affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

On 01-09-2018 at 3:21 p.m., observation in the 2nd floor patient recovery suite, at the south set of cross corridor doors near patient room 208 revealed the cross corridor doors were equiped with two (2) manually operated steel slide bolts on the egress side of the doors that would latch the two doors together preventing egress through them in either direction.

This deficiency was confirmed at the time of discovery by a concurrent interview with Staff D and Staff K.

Based on observation and staff interview, the facility did not ensure that hazardous areas are protected in accordance with the requirements of NFPA 101 (2012 edition), 19.3.2.1.3. This deficient practice could affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

On 01-09-2018 at 2:47 p.m., observation at the laundry room revealed the inactive leaf of the laundry room door to the exit access corridor was damaged at the top with part of the wood missing, and the door would not fully self-close and latch. The inactive leaf of the door was held together by 5 wood screws at the top of the door.

This deficiency was confirmed at the time of discovery by a concurrent interview with Staff D and Staff K.

Based on observation and staff interview, the facility did not ensure that a placard was in place near the kitchen k-type fire extinguisher in accordance with NFPA 101 (2012 edition), 19.3.2.5.3(8) and NFPA 96 (2011 edition), 10.2.2. This deficient practice could affect an undetermined number of inpatients, outpatients, staff and visitors.

Findings include:

On 01-09-2018 at 2:20 p.m., observation in the kitchen revealed that a placard was missing near the k-type fire extinguisher that states the fire protection system shall be activated prior to using the fire extinguisher.

This deficiency was confirmed at the time of discovery by a concurrent interview with Staff D and Staff K.

Based on observation and staff interview, the facility did not ensure that the smoke detectors, for the fire alarm system, are installed per NFPA 101 (2012 edition), 9.6 and NFPA 72 (2010 edition), 17.7.4.1. These deficient practices could affect all 17 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 01-09-2018 at 3:32 p.m., observation in the 2nd floor corridor outside of patient room 253 revealed that a smoke detector was installed within the airflow of a supply diffuser.

2. On 01-09-2018 at 3:39 p.m., observation at the smoke barrier doors between the Obstetrics suite and the Surgery suite revealed that a smoke detector was installed within the airflow of a supply diffuser.

3. On 01-10-2018 at 9:30 a.m., observation in the staff break room on 2nd floor, across from room 234, revealed that a smoke detector was installed within the airflow of a supply diffuser.

4. On 01-10-2018 at 9:58 a.m., observation in the 1st floor corridor outside of the breast pump room revealed that a smoke detector was installed within the airflow of a supply diffuser.

5. On 01-10-2018 at 10:02 a.m., observation in the corridor west of patient registration revealed that a smoke detector was installed within the airflow of a supply diffuser.

6. On 01-10-2018 at 10:04 a.m., observation in the main entrance lobby north of patient registration revealed that a smoke detector was installed within the airflow of a supply diffuser.

These deficiencies were confirmed at the time of discovery by a concurrent interview with Staff D and Staff K.

Based on observation and staff interview, the facility did not ensure that all sprinklers within a smoke compartment are either quick-response or standard response sprinkler heads in accordance with NFPA 101 (2012 edition), 19.3.5.1, 9.7.1.1 and NFPA 13 (2010 edition), 8.3.3.2 and 8.3.3.4. These deficient practices could affect all 17 inpatients and an undetermined number of outpatients, staff and visitors.

Findings Include:

1. On 01-10-2018 at 8:50 a.m., observation in the lower level corridor HLL02 and office LL003 revealed quick-response sprinkler heads installed in the corridor HLL02 and standard response heads installed in the office LL003. These rooms exist in the same smoke compartment.

2. On 01-10-2018 at 9:45 a.m., observation in the 1st floor cardiac rehab area revealed quick-response sprinkler heads installed in room 188 and standard response sprinkler heads installed in room 184. These rooms are open to each other and exist in the same smoke compartment.

These deficiencies were confirmed at the time of discovery by a concurrent interview with Staff D and Staff K.

Based on observation and staff interview, the facility did not ensure that a battery powered emergency light is provided in the transfer switch room in accordance with NFPA 101 (2012 edition), 9.1.3.1 and NFPA 110 (2010 edition), 7.3. This deficient practice could affect all 17 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

On 01-09-18 at 1:15 p.m., observation in the lower level mechanical room LLM001 revealed that no battery powered emergency lighting was provided in the room with the transfer switch.

This deficiency was confirmed at the time of discovery by a concurrent interview with Staff D and Staff K.