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Based on observation and interview, the facility failed to protect a hazardous areas in accordance with the requirements of NFPA 101 (2012 edition), 19.3.2.1.3. This deficient practice could affect an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 12/05/17 at 2:34 pm, observation revealed the CS Storage room door to the clean corridor did not fully self-close and latch.
2. On 12/05/17 at 2:36 pm, observation revealed the sterilization room door to the clean supply room did not fully self-close and latch.
3. On 12/05/17 at 3:36 pm, observation revealed the spare office in the administration suite is used for storage, is larger than 100 sq. ft. and is not protected as hazardous.
4. On 12/06/17 at 11:00 am, observation revealed the shower rooms across from the nurse station in the Riverside Clinic Wing are used for storage, are larger than 100 sq. ft. and are not protected as hazardous.
5. On 12/06/17 at 11:20 am, observation revealed the elevator #2 machine room door did not fully self-close and latch.
6. On 12/06/17 at 11:25 am, observation revealed the kitchen double doors did not fully self-close and latch.
7. On 12/06/17 at 11:30 am, observation revealed the women's locker, is used for storage, is larger than 100 sq. ft. and the door did not fully self-close and latch.
8. On 12/06/17 at 11:50 am, observation revealed storage room G1, is used for storage, is larger than 100 sq. ft. and the door did not fully self-close and latch.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff E.

Based on observation and interview, the facility failed to provide smoke detection in spaces open to the corridor in accordance with NFPA 101 - 2012 edition, section 19.3.6.1. This deficient practice could affect an undetermined number of outpatients, staff and visitors.

Findings include:

On 12/05/2017 at 4:00 pm, observation revealed the Riverside Clinic reception room was open to the corridor and was not located to allow direct supervision from a nurse station and was not protected by an electronically supervised automatic smoke detector.

This finding was confirmed at the time of discovery by an interview with Staff E.

Based on observation and interview, the facility failed to install the sprinkler system in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.5, 19.3.5.3 and 9.7: NFPA 13 - 2010 edition, Section 6.7. This deficient practice could affect 6 of 6 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

On 12/06/17 at 11:42 am, observation revealed that the post indicator valve in the sprinkler system water supply located outside of the building was not supervised by the fire alarm system.

This finding was confirmed at the time of discovery by an interview with Staff E.

Based on observation and staff interview, the facility failed to maintain corridor doors in accordance with NFPA 101(2012 ed.) 19.3.6.3. This deficient practice could affect an undetermined number of outpatients, staff and visitors.

Findings include:
1. On 12/05/17 at 2:30 pm observation revealed that the clean corridor door to the operating suite changing rooms did not fully close and latch.
2. On 12/05/17 at 3:00 pm observation revealed that the east corridor door to the imaging suite did not fully close and latch.
3. On 12/05/17 at 3:20 pm observation revealed that the corridor door to the mammography suite did not fully close and latch.

This finding was confirmed at the time of discovery by an interview with Staff E.

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments, in accordance with the requirements of NFPA 101 (2012 edition.), 19.3.7.8. This deficient practice could affect an undetermined number of outpatients, staff and visitors.

Findings include:
1. On 12/05/2017 at 3:25 pm, observation revealed in the lobby corridor, between the lobby and imaging department, the smoke barrier doors did not fully close. The doors were installed with automatic latching hardware but the doors did not automatically latch which held the doors open.
2. On 12/05/17 at 3:39 pm, observation revealed the 1 ½ hour rated smoke doors at the entrance to the chapel did not fully close. The doors were installed with automatic latching hardware but the doors did not automatically latch which held the doors open.

This finding was confirmed at the time of discovery by an interview with Staff E.

Based on observation and interview, the facility did not provide a ventilation system in accordance with NFPA 101 (2012 ed.), 19.5.2.1, 9.2 and NFPA 90A, (2012 ed.) 4.3.12 with corridor used as a portion of a supply, return, or exhaust air system. This deficient practice could affect 6 of 6 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

1. On 12/06/17 at 10:38 am, it was observed that the corridor within the Med/Surg wing [First floor] of the hospital is being used as a return air plenum for the patient and ancillary rooms along this corridor.
2. On 12/06/17 at 10:40 am, it was observed that the East and West wing [First floor] of the hospital patient rooms do not have any air changes provided from the ventilation system. No supply air is being provided to these rooms as well.

This finding was confirmed at the time of discovery by an interview with Staff E. Staff E stated that this issue has been investigated and there is no ceiling height available to install new ductwork to alleviate this code violation. He also stated that the HVAC system shuts down upon the activation of the fire alarm system.

Based on record review and interview the facility failed to conduct fire drills in accordance with, the requirements of NFPA 101 - 2012 edition, Sections 4.7.1, 4.7.2, 4.7.6, 19.7.1, 19.7.1.4 and 19.7.1.6. This deficient practice could affect 6 of 6 inpatients and an undetermined number of outpatients, staff and visitors.

Findings include:

On 12/05/17 at 1:46 pm, it was noted during review of the facility fire drills for the last 12 months that 3 of 4 2nd shift drills were conducted between 3:42 pm and 4:29 pm and 4 of 4 3rd shift drills were conducted between 6:19 am and 6:45 am, which is not varied throughout the shift.

This finding was confirmed at the time of discovery by an interview with Staff E.

Based upon observation and staff interview, the facility did not provide a remote manual stop station per NFPA 110 - 2010 edition section 5.6.5.6. This deficient practice could affect an undeterminable number of staff with access to the generator room.

Findings include:

On 12/06/17 at 11:45 am, observation revealed the facility did not have a remote manual stop station installed outside of the generator housing.

This finding was confirmed at the time of discovery by an interview with Staff E.