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. Based on observation and staff interview the facility is not ensuring that doors to patient rooms and other ancillary areas are free of impediments that would prevent the doors from being closed. This deficient practice would prevent the doors from being closed quickly in an emergency and would not resist the passage of smoke, affecting 1 of the 3 smoke zones. This facility has a capacity of 10 and a census of 6 at the time of the survey.

FINDINGS INCLUDE:

During the tour on 10/19/2010 between 9:30 A.M. and 2:00 P.M. the following is observed:

--1. The corridor door to patient room #2 was blocked open by exam gloves.

Staff A was present and is aware of this finding.

. Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 2 of 3 smoke zones. This facility has a capacity of 10 and a census of 6 patients at the time of the survey.

FINDINGS INCLUDE:

During the tour on 10/19/2010 between 9:30 A.M. and 2:00 P.M., the following is observed:

--1. 2nd floor biohazard room across from room #2, double doors has one door not positive latching and there is a gap between the doors when closed;
--2. Room #7 is being used for storage, and the door is not self-closing, this door was found in the open position;
--3. First floor vacuum pump room double doors to the corridor has a gap between the doors when closed.
--4. First floor custodial closet by the MRI, door found blocked open.

Staff A and staff B were present and are aware of these findings.

Based on observation, record reviews, and staff interview, the facility failed to assure that emergency lights are in all required areas, operate under test, and are tested for 90 minutes annually and documented. This deficient practice fails to provide emergency lighting of at least 90 minutes, affecting 3 of the 3 smoke zones. The facility has a capacity of 10 with a census of 6.

FINDINGS INCLUDE:

During the tour and record review on 10/19/2010 between 9:30 A.M. and 2:00 P.M., the following is observed:

--1. All of the surgery rooms do not provide battery type emergency lights;
--2. In the north stairway on the first floor landing, the emergency light unit did not operate under test;
--3. There was no record indicating that the battery powered emergency lighting was tested for 90 minutes annually.

Staff A, staff B, and/or staff C was present and is aware of these findings.

. Based on record review and staff interview the facility failed to assure that fire drills are held at least quarterly on each shift. This deficient practice may prevent proper evacuation in a timely manner due to staff ' s inability to respond in the event of an emergency, affecting 3 out of 3 smoke zones. This facility has a capacity of 10 beds with a census of 6 patients at the time of the survey.

FINDINGS INCLUDE:

During the tour on 10/19/10 Between 9:30 A.M. to 2:00 P.M., it was observed during record reviews:

--1. The night shift during the forth quarter of 2009 and the first quarter of 2010 did not conduct a fire drill;
--2. documentation shows the fire drills conducted on 6-24-2010 and 8-25-2010 were before 9:00 P.M., and the fire alarm system was not used for the drills.

Staff A and staff C were present and is aware of these findings.

. Based on record reviews and staff interview, the facility failed to assure that the sensitivity testing of the smoke detectors was done at the appropriate time, failing to ensure that the smoke detectors will operate within the manufacturer's specifications for the building, affecting all 3 of 3 smoke zones. The facility has a capacity of 10 beds with a census of 6.

FINDINGS INCLUDE:

During the survey and record review on 10/19/2010 between 9:30 A.M. and 2:00 P.M. the following is observed:

--1. There is no documentation of a sensitivity test of the smoke detectors.

Staff A and staff C were present and is aware of this finding.

. Based on observation, record review, and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 3 of the 3 smoke zones. The facility has the capacity for 10 beds with a census of 6 patients.

FINDINGS INCLUDE:
During the tour and record review on 10/19/2010 between 9:30 A.M. and 2:00 P.M., the following is observed:

--1. first floor southeast electrical room has a sprinkler missing its escutcheon ring;
--2. documentation of the annual inspection and testing of the fire sprinkler system is not in accordance with NFPA 13 and 25 standard.

Staff A and staff C were present and is aware of these findings.

. Based on observation and staff interview the facility fails to assure that means of egress are clear of any obstructions. This deficient practice could delay exiting in the event of a fire or other emergency situation, affecting 1 of 3 smoke zones. The facility has a capacity of 10 and a census of 6.

FINDINGS INCLUDE:

During the tour on 10/19/2010 between 9:30 A.M. and 2:00 P.M. the following is observed:

--1. 2nd floor corridor by room 5 has storage of a housekeeping cart unattended for over 30 minutes.

Staff A and Staff B were present and is aware of this finding.