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Based on observation, the facility failed to provide partitions that resist the passage of smoke in a non-sprinkled building as directed by NFPA 101 Chapter 19.3.6.2.2.

Findings include:

While inspecting corridor walls on 04-15-15 at 10:29 a.m., the surveyor and maintenance supervisor observed open penetrations in the corridor wall on the 2nd floor near Room 200.

The maintenance supervisor and the COO were notified during an exit conference. This deficient practice affected 1 of 3 smoke compartments.

19.3.6.1
Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.)

19.3.6.2.2*
Corridor walls shall form a barrier to limit the transfer of smoke.

Based on observations, the facility failed to provide the required smoke resistive, positive latching, solid wood corridor doors. Referenced Regulation Minimum Standards of Operation for Mississippi Hospitals, Section 107.02-2.

While inspecting corridor doors on 04/15/09 at 11:25 a.m., the surveyor observed the following corridor doors with deficiencies:

1. Server Room on 2nd floor was found with air transfer grille in door.
2. Server Room on 3rd floor was found with air transfer grille in door.

This deficient practice has the potential of affecting 1 of 3 smoke compartments on each of the floors where found. The COO and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to properly protect hazardous areas. These conditions affected 100% of the residents and staff.

Findings include:

On 4/15/2015 at 2:35 p.m., the maintenance person and surveyor found that the following hazardous areas have numerous openings and penetrations in non-sprinkled facility:

1. Materials Management Office did not provide the required 1 hour fire protection rating for hazardous area above ceiling and did not have rated glass in the door.

2. Mechanical Room in Radiology did not provide the required 1 hour fire protection. The wall mounted A/C unit installed in concrete block wall has an open gap in wall around the A/C unit.

3. Radiology Medical Records Room on 1st floor did not provide the required 1 hour fire protection rating for hazardous area above ceiling.

This deficient practice has the potential of affecting 100% of the residents and staff. The COO and maintenance director were notified during the survey and in the exit conference.

Based on observation, the facility failed to provide clear and unobstructed corridors serving as exit access.

Findings Include:

On 4/15/2015 at 1:00 p.m., the maintenance person and surveyor observed two fully loaded dollies and other boxes in the corridor leading to loading dock on the 1st floor.

This deficient practice has the potential of affecting 1 of 5 exits on the 1st floor. The COO and maintenance director were notified during the survey and in the exit conference.

Based on documentation review, the facility failed to properly inspect the generator as directed by NFPA 110. This condition affected 100% of the residents and staff.

Findings include:

On 4/15/2015 at 2:45 p.m., the maintenance person could not produce documentation showing the annual inspection/preventative maintenance of the generator for the past 12 months.

The COO and maintenance director were notified during the survey and in the exit conference.

Based on observation, the facility failed to provide partitions that resist the passage of smoke in a non-sprinkled building as directed by NFPA 101 Chapter 19.3.6.2.2.

Findings include:

While inspecting corridor walls on 04-15-15 at 10:29 a.m., the surveyor and maintenance supervisor observed open penetrations in the corridor wall on the 2nd floor near Room 200.

The maintenance supervisor and the COO were notified during an exit conference. This deficient practice affected 1 of 3 smoke compartments.

19.3.6.1
Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.)

19.3.6.2.2*
Corridor walls shall form a barrier to limit the transfer of smoke.

Based on observations, the facility failed to provide the required smoke resistive, positive latching, solid wood corridor doors. Referenced Regulation Minimum Standards of Operation for Mississippi Hospitals, Section 107.02-2.

While inspecting corridor doors on 04/15/09 at 11:25 a.m., the surveyor observed the following corridor doors with deficiencies:

1. Server Room on 2nd floor was found with air transfer grille in door.
2. Server Room on 3rd floor was found with air transfer grille in door.

This deficient practice has the potential of affecting 1 of 3 smoke compartments on each of the floors where found. The COO and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to properly protect hazardous areas. These conditions affected 100% of the residents and staff.

Findings include:

On 4/15/2015 at 2:35 p.m., the maintenance person and surveyor found that the following hazardous areas have numerous openings and penetrations in non-sprinkled facility:

1. Materials Management Office did not provide the required 1 hour fire protection rating for hazardous area above ceiling and did not have rated glass in the door.

2. Mechanical Room in Radiology did not provide the required 1 hour fire protection. The wall mounted A/C unit installed in concrete block wall has an open gap in wall around the A/C unit.

3. Radiology Medical Records Room on 1st floor did not provide the required 1 hour fire protection rating for hazardous area above ceiling.

This deficient practice has the potential of affecting 100% of the residents and staff. The COO and maintenance director were notified during the survey and in the exit conference.

Based on observation, the facility failed to provide clear and unobstructed corridors serving as exit access.

Findings Include:

On 4/15/2015 at 1:00 p.m., the maintenance person and surveyor observed two fully loaded dollies and other boxes in the corridor leading to loading dock on the 1st floor.

This deficient practice has the potential of affecting 1 of 5 exits on the 1st floor. The COO and maintenance director were notified during the survey and in the exit conference.

Based on documentation review, the facility failed to properly inspect the generator as directed by NFPA 110. This condition affected 100% of the residents and staff.

Findings include:

On 4/15/2015 at 2:45 p.m., the maintenance person could not produce documentation showing the annual inspection/preventative maintenance of the generator for the past 12 months.

The COO and maintenance director were notified during the survey and in the exit conference.