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Based on observation and interview with staff, the facility failed to provide corridors separated by use areas by walls with at least one-half hour fire resistance rating. Findings:

1) The Clean Linen Room (across from Nurse Station) is open to the corridor,and has an unrated folding partition type door. There is not a one-half hour fire resistance rating separating this room from the corridor. Refer to 19.3.6.1.

Based on observation and interview with staff, the facility failed to provide doors with a means suitable for keeping the door closed, and failed to provide no impediment to the closing of the doors. Findings:

1) Roller latches were found on the doors to Patient Rooms 101 and 102. Roller latches are prohibited by CMS regulations.

2) There is no latching hardware at several doors, including these locations: Oxygen Room, Convenience Care, Ultra Scan, Lab, X-Ray. Refer to 19.3.6.3.2.

3) The Dutch Door at Outpatient Registration is required to have a latching device on the upper leaf and the lower leaf, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. Refer to 19.3.6.3.6.

4) Door stops were found on several doors, including these locations: Housekeeping, Large ER Exam, X-Ray, Copy Room, Payroll. Refer to 19.3.6.3.3.

Based on observation and interview with staff, the facility failed to provide two exits, remote from each other. Findings:

1) The exterior pair of doors providing the second exit from the Boiler Room are padlocked, requiring the use of a key to exit this space.

Based on observation and interview with staff, the facility failed to provide patient room doors arranged so that patients can always open the door from inside without using a key. Findings:

1) Dead-bolt locking devices were found on the doors to Patient Rooms 101 and 102. Locks are not permitted on patient sleeping room doors. Refer to 19.2.2.2.2.

Based on observation and interview with staff, the facility failed to conduct fire drills at least quarterly on each shift. Findings:

1) The only documented fire drill found was dated March 29, 2013. Fire drills are not being conducted at least quarterly on each shift. Refer to 19.7.1.2.

Based on observation and interview with staff, the facility failed to provide automatic sprinler systems installed per NFPA 13. Findings:

1) The Kitchen Supply Room and the narrow supply area have sloped ceilings that reach above the height of the fire sprinkler heads. Supplies are stored on shelving above the sprinkler heads. NFPA 13, 5-5.6 reads "the clearance between the deflector and the top of storage to be 18" or greater." The supplies stored on the shelving shall be at least 18" below the sprinkler head.

2) Documentation of annual fire sprinkler inspections could not be produced.

Based on observation and interview with staff, the facility failed to provide HVAC complying with provisions of 19.5.2.1 and 9.2. Findings:

1) Exhaust fans, including those in toilet rooms, are not functioning due to fans not in operating condition. In some locations, exhaust fan grilles were covered solid with dirt and grime, making them inoperable.

Based on observation and interview with staff, the facility failed to provide a Type 1 Essential Electrical system in accordance with NFPA 99. Findings:

1) A remote annunciator, storage battery powered, shall be provided to operate outside of the generating area in a location readily observed by operating personnel at a regular work station. The facility does not have a remote annunciator. Refer to 3-4.1.1.15.

Based on observation and interview with staff, the facility failed to provide continuing safety education and supervision in accordance with NFPA 99. Findings:

1) Procedures for action following chemical spills in the Lab were not found in the Emergency Procedures manual. When asked, the staff stated that procedures for chemical spills is not in the manual. Refer to 10-2.1.4.2.

Based on observation and interview with staff, the facility failed to provide electrical wiring in accordance with NFPA 70, National Electrical Code. Findings:

1) Open junction boxes (electrical boxes with no cover plate) were found in the ceiling above outpatient registration. Cover plates are required per 314.28(C).