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Based on observations, the facility failed to properly protect corridor openings, in accordance with NFPA 101 section 19.3.6.3. The deficient practice affected three (3) of nine (9) smoke compartments on the day of the survey.

Findings Include:

On 7/19/16 at 11:45 AM, observation revealed corridor doors with locks greater than 48 inches from finished floor with double key dead bolts in the following areas of the facility:

1) Emergency Rooms 1 and 2
2) Room 210 in Surgery Area
3) Recovery Room in Surgery Area
4) Patient Room 1093

The finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview on 7/19/16.

Based on observations, the facility failed to protect hazardous areas in accordance with NFPA 101 section 19.3.7.3. The deficient practice affected one (1) of nine (9) smoke compartments on the day of the survey.

Findings Include:

On 7/19/16 at 3:25 PM, observation revealed the Soiled Linen Room in Zone 1 has an non rated fire door and was unsealed above ceiling.

The finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview on 7/19/16.

Based on observations and testing, the facility failed to properly maintain the exit egress as required by NFPA 101 sections 19.2.1, 7.7. The deficiency affected three (3) of nine (9) smoke compartments on the day of the survey.

Findings Include:

On 7/19/16 at 11:40 AM, observation revealed the following exits restricted outside access:

1. South Wing exit sidewalk does not extend to the public way.
2. North Wing exit sidewalk has eroded away which created an unclear, unaccessible path access to the public way.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 7/19/16.

Based on observation, the facility failed to provide clear and unobstructed exit access as required by the NFPA 101 sections 19.2.3.3. The deficiency affected one (1) of nine (9) smoke compartments on the day of the survey.

Findings Include:

On 7/19/16 at 11:49 AM, observation revealed exercise equipment blocking and obstructing the means of egress to the Therapy Hall of the facility.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 7/19/16.

Based on record review, the facility failed to properly maintain the fire alarm system as directed by, NFPA 72 code 1-5.4.6, and NFPA 101 section 9.6. The deficient practice affected all nine (9) smoke compartments of the facility.

Findings Include:

While performing record review on 7/19/16 at 1:20 PM , it was determined that the fire alarm inspection performed on 4/5/16 indicated problems with six (6) detectors, 1 phone dialer and the control panel. The facility could not produce documentation of corrective action of these problems discovered on the annual fire alarm inspection.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview 7/19/16.

Based on observations, the facility failed to properly protect corridor openings, in accordance with NFPA 101 section 19.3.6.3. The deficient practice affected three (3) of nine (9) smoke compartments on the day of the survey.

Findings Include:

On 7/19/16 at 11:45 AM, observation revealed corridor doors with locks greater than 48 inches from finished floor with double key dead bolts in the following areas of the facility:

1) Emergency Rooms 1 and 2
2) Room 210 in Surgery Area
3) Recovery Room in Surgery Area
4) Patient Room 1093

The finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview on 7/19/16.

Based on observations, the facility failed to protect hazardous areas in accordance with NFPA 101 section 19.3.7.3. The deficient practice affected one (1) of nine (9) smoke compartments on the day of the survey.

Findings Include:

On 7/19/16 at 3:25 PM, observation revealed the Soiled Linen Room in Zone 1 has an non rated fire door and was unsealed above ceiling.

The finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview on 7/19/16.

Based on observations and testing, the facility failed to properly maintain the exit egress as required by NFPA 101 sections 19.2.1, 7.7. The deficiency affected three (3) of nine (9) smoke compartments on the day of the survey.

Findings Include:

On 7/19/16 at 11:40 AM, observation revealed the following exits restricted outside access:

1. South Wing exit sidewalk does not extend to the public way.
2. North Wing exit sidewalk has eroded away which created an unclear, unaccessible path access to the public way.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 7/19/16.

Based on observation, the facility failed to provide clear and unobstructed exit access as required by the NFPA 101 sections 19.2.3.3. The deficiency affected one (1) of nine (9) smoke compartments on the day of the survey.

Findings Include:

On 7/19/16 at 11:49 AM, observation revealed exercise equipment blocking and obstructing the means of egress to the Therapy Hall of the facility.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 7/19/16.

Based on record review, the facility failed to properly maintain the fire alarm system as directed by, NFPA 72 code 1-5.4.6, and NFPA 101 section 9.6. The deficient practice affected all nine (9) smoke compartments of the facility.

Findings Include:

While performing record review on 7/19/16 at 1:20 PM , it was determined that the fire alarm inspection performed on 4/5/16 indicated problems with six (6) detectors, 1 phone dialer and the control panel. The facility could not produce documentation of corrective action of these problems discovered on the annual fire alarm inspection.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview 7/19/16.