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Based upon observation and staff interviews, the facility failed to maintain corridor walls separated from use areas by walls constructed with 1/2 hour fire resistance rating which will resist the passage of smoke in the event of a fire. In the event of a fire, this would allow smoke to move between the rooms and the exit access corridor and thus place patients, visitors, and staff at risk of smoke and fire.

During the facility tour on September 24, 2013 between the hours of 1:00pm and 2:30pm, the following penetrations were found:

1. At 2:00pm, I observed that the mop closet at ER entrance has a penetration in the ceiling.
2. At 2:05pm, I observed that the lab closet has a penetration in the wall.

These findings were observed and discussed with the Maintenance Director.

Based on observation and staff interview the facility failed to assure that door openings closed to resist the passage of smoke to corridors. This potentially cause the quick spread of smoke, heat and fire, and thus expose patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

During the facility tour conducted on September 24, 2013 between the hours of 1:00pm and 2:30pm, doors did not properly close and latch in the following locations:

1. At 1:45pm, I observed that the main lobby door did not close and latch when tested.
2. At 2:02pm, I observed that the ER door did not close and latch when tested.
3. At 2:02pm, I observed that the CT-room door did not close and latch when tested.
4. At 2:08pm, I observed that the Clinic patient room #4 did not close and latch properly when tested.

These findings were observed and discussed with the Maintenance Director.

Based on observations made during the survey tour from 1:00pm to 2:30pm, and document review, the facility has failed to provide automatic sprinkler detection system on the first floor of the building as required. This places patients, visitors, and staff at risk of fire without an automatic extinguishing system.

The findings include, but are not limited to:

1. Survey tour and document review conducted today, September 24, 2013, revealed that the facility has not provided the first floor of the building with automatic sprinkler protection as required. Documentation provided by the facility revealed that a bid has been received for the project. No other action has been taken to install a sprinkler system on the first floor of the building as required.

2. At 1:15pm, I observed that the sprinkler riser room door did not have identication sign indicating "Sprinkler Control Valve Room."

This finding was observed and discussed with the Maintenance Director and Administration Staff.

Based on observation and interview with staff the facility failed to properly divide the various branches of the essential electrical system (EES). More specifically, separation of the life safety and the critical branch.

Failure on the part of the facility to properly divide the various branches of the EEs places patients, staff, and visitors of the facility at risk from the effects of an essential electrical system malfunction.

Findings include, but are not limited to:

1. The facility was cited in the August 18, 2011 survey for failure to divide the life safety and the critical branches as required.

2. Reinspection on 01/12/2012 revealed that the facility had contacted a mechanical engineer and had forwarded to Department of Health a proposed action plan. No documentation was available at that time that indicated the proposed action plan was acceptable.

3. Survey conducted today, September 24, 2013, revealed that a bid proposal was received by the facility. No action has been taken to divide the life safety and critical branches as required.

This finding was observed and discussed with the Maintenance Director and Admnistration Staff.

The facility has failed to maintain premises free of electrical hazards. This could provide for electrical fire and expose staff and patients to threat of fire.

The findings include, but are not limited to:

During the facility survey on September 24, 2013 from approximately 1:00pm to 2:30pm, electrical hazards were observed in the following location(s):

1. At 1:11pm, I observed that the IT back room has power strip into power strip. Also IT back room has a 3rd power strip not properly mounted and is dangling adding stress on cords creating a fire hazard.
2. At 1:16pm, I observed an unapproved adaptor in the Medical Records office.
3. At 1:16pm, I observed that the main electrical room did not have an identification sign on the door indicating "Electrical Room".
4. At 2:04pm, I observed that Central Supply has power strip into power strip.

These findings were observed and discussed with the Maintenance Director.

Based upon observation and staff interviews, the facility failed to maintain corridor walls separated from use areas by walls constructed with 1/2 hour fire resistance rating which will resist the passage of smoke in the event of a fire. In the event of a fire, this would allow smoke to move between the rooms and the exit access corridor and thus place patients, visitors, and staff at risk of smoke and fire.

During the facility tour on September 24, 2013 between the hours of 1:00pm and 2:30pm, the following penetrations were found:

1. At 2:00pm, I observed that the mop closet at ER entrance has a penetration in the ceiling.
2. At 2:05pm, I observed that the lab closet has a penetration in the wall.

These findings were observed and discussed with the Maintenance Director.

Based on observation and staff interview the facility failed to assure that door openings closed to resist the passage of smoke to corridors. This potentially cause the quick spread of smoke, heat and fire, and thus expose patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

During the facility tour conducted on September 24, 2013 between the hours of 1:00pm and 2:30pm, doors did not properly close and latch in the following locations:

1. At 1:45pm, I observed that the main lobby door did not close and latch when tested.
2. At 2:02pm, I observed that the ER door did not close and latch when tested.
3. At 2:02pm, I observed that the CT-room door did not close and latch when tested.
4. At 2:08pm, I observed that the Clinic patient room #4 did not close and latch properly when tested.

These findings were observed and discussed with the Maintenance Director.

Based on observations made during the survey tour from 1:00pm to 2:30pm, and document review, the facility has failed to provide automatic sprinkler detection system on the first floor of the building as required. This places patients, visitors, and staff at risk of fire without an automatic extinguishing system.

The findings include, but are not limited to:

1. Survey tour and document review conducted today, September 24, 2013, revealed that the facility has not provided the first floor of the building with automatic sprinkler protection as required. Documentation provided by the facility revealed that a bid has been received for the project. No other action has been taken to install a sprinkler system on the first floor of the building as required.

2. At 1:15pm, I observed that the sprinkler riser room door did not have identication sign indicating "Sprinkler Control Valve Room."

This finding was observed and discussed with the Maintenance Director and Administration Staff.

Based on observation and interview with staff the facility failed to properly divide the various branches of the essential electrical system (EES). More specifically, separation of the life safety and the critical branch.

Failure on the part of the facility to properly divide the various branches of the EEs places patients, staff, and visitors of the facility at risk from the effects of an essential electrical system malfunction.

Findings include, but are not limited to:

1. The facility was cited in the August 18, 2011 survey for failure to divide the life safety and the critical branches as required.

2. Reinspection on 01/12/2012 revealed that the facility had contacted a mechanical engineer and had forwarded to Department of Health a proposed action plan. No documentation was available at that time that indicated the proposed action plan was acceptable.

3. Survey conducted today, September 24, 2013, revealed that a bid proposal was received by the facility. No action has been taken to divide the life safety and critical branches as required.

This finding was observed and discussed with the Maintenance Director and Admnistration Staff.

The facility has failed to maintain premises free of electrical hazards. This could provide for electrical fire and expose staff and patients to threat of fire.

The findings include, but are not limited to:

During the facility survey on September 24, 2013 from approximately 1:00pm to 2:30pm, electrical hazards were observed in the following location(s):

1. At 1:11pm, I observed that the IT back room has power strip into power strip. Also IT back room has a 3rd power strip not properly mounted and is dangling adding stress on cords creating a fire hazard.
2. At 1:16pm, I observed an unapproved adaptor in the Medical Records office.
3. At 1:16pm, I observed that the main electrical room did not have an identification sign on the door indicating "Electrical Room".
4. At 2:04pm, I observed that Central Supply has power strip into power strip.

These findings were observed and discussed with the Maintenance Director.