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Based on observation, interview, and record review, the provider failed to maintain proper separation between the hospital and one of two non-healthcare occupancies (attached apartments). Findings include:

1. Observation at 10:35 a.m. on 1/14/2020 revealed the ninety-minute, fire rated door in the two-hour fire separation wall between the hospital and attached apartments would not latch with the door closer. Interview with the facility director at the time of the observation confirmed the findings. He stated he was unaware the door would not latch and needed to monitor the doors in the fire separation walls more frequently.

Record review of the previous survey in 2016 revealed that location had been previously identified as not compliant with the requirements for building separations.

The deficiency had the potential to affect the current patient (possible twenty-five patients) and staff.

Based on observation, testing, and interview, the provider failed to maintain means of egress free of obstruction as required at one randomly observed corridor door location (X-Ray room). Findings include:

1. Observation beginning at 3:39 p.m. on 1/14/2020 revealed the corridor door to the X-Ray room had a deadbolt installed separate from the door handle. That deadbolt could impede egress in an emergency situation. Testing of that door revealed it would not open with a single action as required when the deadbolt was locked.

Interview at the time of the observation with the maintenance supervisor confirmed those conditions. He stated he was unaware that deadbolt created an issue.

Failure to provide working egress doors as required increases the risk of death or injury due to fire.

The deficiency affected 100% of the X-ray room occupants.

Based on observation, record review, and interview, the provider failed to maintain operational battery pack emergency lighting for one observed location (electrical room). Findings include:

1. Observation at 1:14 p.m. on 1/14/2020 revealed the battery pack emergency light for the electrical room was not functioning when tested using the built-in testing button. Record review that same day revealed no record existed for the required monthly or annual tests.

Interview with the maintenance supervisor at the time of the above observation confirmed that finding. He further stated he was unaware of the requirements of monthly and annual testing.

The deficiency affected any occupant in the electrical room.