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Based on observations, the facility failed to properly protect corridor openings, in accordance with NFPA 101 section 19.3.6.3. The deficient practice affected all two (2) smoke compartments on the day of the survey.

Findings Include:

On 5/18/16 at 11:45AM, observation revealed the following corridor openings:

1) The doors to Case Manager ' s Office, Eye Wash Station, Operating Room 1 and Operating Room 2 have open penetrations.

2) Doors to Operating Room 1 and 2 had need an astragal.

3) Door to Business Manager ' s Office has a roller latch.

4) The doors to Pharmacy, Janitor ' s closet, Bathroom near Manager Office, Bedrooms 112, 113, 114, 116, 117, and 123 lacked a positive device.

The finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview on 5/18/16.

Based on observations, the facility failed to provide a one half hour rating in accordance with NFPA 101 sections 8.3, 19.3.7.3, 19.3.7.5.The deficient practice affected two (2) of two (2) smoke compartments on the day of the survey.

Findings Include:

On 5/18/16 at 1:55 PM, observation revealed numerous open penetrations in the one (1) smoke barrier wall of the facility. The maintenance personnel were advised that we will do a full inspection of smoke barrier walls upon revisit.

The finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview on 5/18/16.

Based on observations, the facility failed to properly protect smoke barrier doors in accordance with NFPA 101 sections 19.2.2.2.6. The deficient practice affected all two (2) smoke compartments on the day of the survey.

Findings include:

On 5/18/16 at 2:30PM, observation revealed missing closers on the following smoke barrier doors of the facility:

1) Case Manager ' s Office
2) Both doors at Chief Clinical Office.

The finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview on 5/18/16.

Based on observations, the facility failed to protect hazardous areas in accordance with NFPA 101 section 19.3.7.3. The deficient practice affected two (2) of two (2) smoke compartments on the day of the survey.

Findings Include:

On 5/18/16 at 11:25AM, observation revealed the following deficiencies of the hazardous areas of the facility.

1) Door to the Biohazard Room lack a positive latching device
2) Soiled Utility Room was missing door closer
3) Door to Storage Room next to Lab lack a positive latching device

The finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview on 5/18/16.

Based on observations, the facility failed to maintain the fire alarm system in accordance with NFPA 72 section 4-4.4.1.1. The deficient practice affected two (2) of two (2) smoke compartments on the day of the survey.

Findings include:

On 5/18/16 at 3:00 PM, observation revealed all the visible alarm devices (strobes) throughout the building were not synchronized. The maintenance personnel were advised that we will do a full inspection of visible alarms upon revisit.

The finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview on 5/18/16.