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Based on random observation during the survey walk-through, not all doors in exit access corridors are in compliance with 19.3.6.3.

Findings include:

A. Doors in exit access corridors were observed that are not positive latching as required by 19.3.6.3.2. This deficiency could affect all inpatients in the 20 bed facility, as well as any staff and visitors present, by allowing smoke to pass from the building's exit access corridors to rooms housing them. Locations observed include:

1. Corrected 07/08/11.

2. 10:26 AM May 25, 2011: The glass and aluminum door to the Administration Suite.

Update 07/08/11: 8:50AM- The surveyor was unable to clear K018 tag Item A2 during this walkthrough. The door to the administration suite was not corrected.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. At 9:54 AM on May 25, 2011, the south leaf of the door from the Medical Office Building to the exit Corridor for the Hospital Nursing Unit was observed to, when in the fully open position, protrude more than 7" into the required clear corridor width as prohibited by 7.2.1.4.4. This deficiency could affect all inpatients in the 20 bed facility, as well as any staff and visitors present, by limiting the space available for them to exit the building through this Corridor.

B. Doors were observed that are equipped with thumbturn deadbolt retractors, thus requiring more than 1 door releasing operation as prohibited by 7.2.1.5.4. These deficiencies could affect all outpatients receiving treatment in the Emergency Department, as well as any staff and visitors present, by preventing them from exiting the building under emergency conditions. Locations observed include:
1. 11:10 AM May 25, 2011: The inner set of automatic sliding doors from the Emergency Department to the exterior.
2. 11:16 AM May 25, 2011: The inner set of automatic sliding doors from the Emergency Department Reception Area to the exterior.

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Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

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