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Based on observation and interview, it was determined the facility failed to maintain doors with self closing devices on one of one floors.

Findings include:

1. Observation on November 12, 2020, at 1:00 p.m., revealed the door for the Admissions Assistant Director's office was held open by a wooden floor chock.

Interview at the time of the exit conference with the Executive Director of Hospital Services and Director of PA Operations on November 12, 2020 at 3:15 p.m., confirmed the door was chocked open.

Based on observation and interview, it was determined the facility failed to ensure that stairways used as exits were not used for any purpose that has the potential to interfere with egress, affecting two of two floors.

Findings include:

1. Observation on November 12, 2020, at 1:35 p.m., revealed several chairs and other miscellaneous items were being stored on the ground floor level, landing of the south central stairtower.

Interview at the time of the exit conference with the Executive Director of Hospital Services and Director of PA Operations on November 12, 2020 at 3:15 p.m., confirmed the items were being stored in the stair tower.

Based on interview and observation, it was determined the facility failed to maintain doors to hazardous areas in three locations.

Findings include:

1. Observation between 2:00 p.m. and 2:15 p.m., revealed the following:

a. At 2:00 p.m., the door to the South Central mechanical room failed to latch in the frame.
b. At 2:15 p.m., the right side storage room in the Core, Gym was not self closing.

Interview at the time of the exit conference with the Executive Director of Hospital Services and Director of PA Operations on November 12, 2020 at 3:15 p.m., confirmed the hazardous area deficiencies.

2. Observation on November 12, 2020, at 2:05 p.m., revealed several unsealed data wire penetrations of the South west Mechanical room walls.

Interview at the time of the exit conference with the Executive Director of Hospital Services and Director of PA Operations on November 12, 2020 at 3:00 p.m., confirmed the open areas around the data wires.

Based on observation and interview, it was determined the facility failed to mainttain the sprinkler system in two locations on one floor.

Findings include:

1. Observation on November 12, 2020, between 1:40 p.m. and 2:55 p.m., revealed the following;

a. At 1:40 p.m., the exit at the South Central stairtower had a combustible overhang of approximatley six feet that lacked sprinkler coverage.

b. At 2:55 p.m., the South Stairtower in the core lacked sprinkler coverage at the ground floor landing.

Interview at the time of the exit conference with the Executive Director of Hospital Services and Director of PA Operations on November 12, 2020 at 3:15p.m., confirmed the lack of sprinkler coverage in the stairtower areas.

Based on observation and interview, it was determined the facility failed to maintain the emergency generator that supplies alternate power to the facility.

Findings include:

1. Observation on November 12, 2020, between 3:00 p.m. and 3:05 p.m., revealed the following:

a. At 3:00 p.m., there was no battery operated emergency light installed in the interior generator room.

b. At 3:05 p.m., the generator lacked an emergency stop button located outside of the room where the generator is located.

Interview at the time of the exit conference with the Executive Director of Hospital Services and Director of PA Operations on November 12, 2020 at 3:15 p.m., confirmed the emergency generator deficiencies.