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Based on observation, staff interviews, and review of maintenance records between March 3, 2014 and March 6, 2014 and during a verification visit on April 21, 2014 the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 485.623: Condition of Participation: Physical Plant and Environment: NOT MET

Findings include:

The facility was found to contain the following deficiencies.
K 29: hazardous areas improperly enclosed;

K130: South Clinic: failed to properly protect the basement and main office which are hazardous areas from the rest of the building; failed to properly protect the north stair well out of the basement; and the doors of the exit enclosure out of the basement were not built to 3/4 hour fire rated construction.
K130: North Clinic: failed to properly protect the furnace room and storage areas; and did not maintain common path of travel within 75 feet.

Refer to the the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, staff interviews, and review of maintenance records between March 3, 2014 and March 6, 2014 and during a verification visit on April 21, 2014 the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 485.623: Condition of Participation: Physical Plant and Environment: NOT MET

Findings include:

The facility was found to contain the following deficiencies.
K 29: hazardous areas improperly enclosed;

K130: South Clinic: failed to properly protect the basement and main office which are hazardous areas from the rest of the building; failed to properly protect the north stair well out of the basement; and the doors of the exit enclosure out of the basement were not built to 3/4 hour fire rated construction.
K130: North Clinic: failed to properly protect the furnace room and storage areas; and did not maintain common path of travel within 75 feet; and

Refer to the the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

12187


Based on observation and interviews with facility staff, the hospital did not ensure that the environment is kept clean, and that there is a system in place to prevent potential sources of contamination and infection. This deficiency potentially affects all 8 patients served at the facility during this survey.

FINDINGS INCLUDE:

1. On 03/04/2014 at 8:50 AM and on April 21, 2014 at 3:15 pm operating room (autoclave area) has a floor drain.

2. On 0304/2014 at 9:05 AM and on April 21, 2014 at 3:20 pm, observation revealed that the air flow for the dirty 'clean up room' was from the room into the corridor, or from dirty to clean. Compliant air flow is from clean to dirty.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff P (Maintenance Supervisor).