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Based on observation, interview, and record review, the facility failed to maintain a two hour barrier between occupancy types, failed to ensure doors equipped with magnetic hold devices released upon activation of the fire alarm system, failed to have corridor doors on self-closer's free of impediments to self close, failed to maintain rating of protective construction surrounding vertical openings, failed to have self closing doors on vertical openings to self close, failed to maintain smoke barriers free of penetrations, failed to have doors in smoke barriers on self closer's and/or completely close, failed to have doors in smoke barriers with pre-existing latching hardware close and latch, failed to test emergency lighting for 90 minutes annually and failed to have sprinklers installed in accordance with National Fire Protection Association 13, 1999 edition, 3-2. (A709). This deficient practice had the potential to affect all 192 patients.

Based on staff interview and review of the Medical Staff Rules and Regulations, the facility failed to ensure all medical records were completed within 30 days of discharge from the facility. This affected 833 medical records. The facility census was 171 at the time of the survey.

Findings include:

Staff B was interviewed on 02/18/15 at 9:00 AM. Staff B stated that 833 medical records were delinquent or incomplete after 30 days post discharge.

Review of the Medical Staff Rules and Regulations revealed all patient charts must be completed no more than 30 days from the date of discharge, including co-signatures and authorizations by the attending or supervising physician. Those charts not meeting this requirement shall be classified as "delinquent".

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all 192 patients.

Findings include:

Building 1
(Main hospital building)

K11 Failed to maintain two hour rating of barrier between two occupancy types
K18 Failed to have corridor doors on self closer's free of impediments to self close
K20 Failed to maintain rating of protective construction surrounding vertical openings
K21 Failed to have self closing doors on vertical openings to self close
K25 Failed to maintain smoke barriers free of penetrations
K27 Failed to have doors in smoke barriers on self closer's and/or completely close
K38 Failed to ensure doors equipped with magnetic hold devices released upon activation of the fire alarm system
K56 Failed to have sprinklers installed in accordance with NFPA 13, 3-2.

Building 2
(In-patient rehab)
K27 Failed to have doors in smoke barriers with pre-existing latching hardware close and latch

Building 3
(Spring Meadows outpatient rehab)
K46 Failed to test emergency lighting for 90 minutes annually