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Based on tour of facility and staff verification it was determined this facility failed to ensure the door of one hazardous area closed properly in order to maintain the one hour fire rated integrity. This had the potential to affect all those utilizing this area of the facility. The facility census at the beginning of the survey was 24.

Findings include:

Tour of the facility took place on 12/14/10 with staff members T and J. During tour of the soiled utility room observation was made of the fire rated door failing to latch securely when closed. The door was closed several times by staff T in order to test the latching device and the door failed to latch securely with each attempt. This was also verified by staff J during tour.

Based on observation and staff verification during tour, it was determined this facility failed to ensure the patient room seclusion door locks operated properly in order to ensure the door could be opened readily in the event of an emergency. This had the potential to affect all those utilizing the seclusion rooms while the door locks were activated. The facility census at the beginning of the survey was 24.

Findings include:

Tour of the facility took place on 12/14/10 with staff members T and J. During tour of the facility, observation was made of two seclusion rooms located behind the medication room. Both seclusion rooms were noted to have doors equipped with three dead bolt locks mounted at the top, middle and bottom of the door. The top and bottom locks were thumb latch dead bolts and the middle lock was keyed. All locks were able to be activated and deactivated from only the outside of the door.
Staff J operated the keyed dead bolt lock of seclusion room number one and observation was made by this surveyor of staff J having a difficult time locking and unlocking the dead bolt. Concerted effort was made during at least a two minute period for staff J to deactivate the keyed dead bolt once it was activated. This surveyor attempted to activate the thumb latch dead bolts on the door of seclusion room number one and had much difficulty activating and deactivating them. Staff T stated they have not used these rooms as seclusion rooms for at least the past two years and the locks will have to be addressed.

Based on documentation review for the emergency battery operated lights and staff interview it was determined this facility failed to ensure the emergency battery operated lights were tested for the required 30 seconds each month and the 90 minute annual test. This had the potential to affect all those utilizing this facility. The facility census at the beginning of the survey was 24.

Findings include:

Documentation review for the emergency battery operated lights took place on 12/13/10. Observation was made of one 30 second monthly test which was performed this December. Request was made for any additional testing reports and staff T stated there were no additional reports available. Staff T also stated they had recently started to document the required monthly and annual testing of the battery operated emergency lights on a newly revised form.

Based on documentation review of smoke detector testing, staff interview and observation during tour it was determined this facility failed to ensure the proper placement of smoke detectors according to the National Fire Protection Association (NFPA) 72 Chapter 2-3.5.1 and failed to maintain documentation regarding the annual testing of smoke detectors including sensitivity testing. This had the potential to affect all those utilizing this facility. The facility census at the beginning of the survey was 24.

Findings include:

A request was made on 12/13/10 for the review of smoke detector testing documentation including sensitivity testing. Staff T stated no documentation was available at this time. Staff T stated this facility has recently initiated a plan to replace all smoke detectors with a new computerized self monitoring system which will enable continuous sensitivity testing of each smoke detector.
Additionally, tour of the facility took place on 12/14/10 with staff members T and J. During tour observation was made of smoke detectors which were mounted near air flow devices in the following areas:
*Within the maintenance shop room
*In the corridor near the east exit door of the 100 wing
*In the dayroom of the 100 wing
*At the exit door near the dayroom of the 200 wing
*Within the corridor outside of room 212 and 216

These findings were verified by staff T and J during tour on 12/14/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure the proper storage of medical gas cylinders within the medical gas storage location. This had the potential to affect all those utilizing this facility. The facility census at the beginning of the survey was 24.

Findings include:

Tour of the facility took place on 12/14/10 with staff T and J. Observation was made within the medical gas storage room of ten E tanks of oxygen, four of which were not secured or placed in a holding device. This finding was verified by staff T and J during tour.

Based on tour of facility and staff verification it was determined this facility failed to ensure the door of one hazardous area closed properly in order to maintain the one hour fire rated integrity. This had the potential to affect all those utilizing this area of the facility. The facility census at the beginning of the survey was 24.

Findings include:

Tour of the facility took place on 12/14/10 with staff members T and J. During tour of the soiled utility room observation was made of the fire rated door failing to latch securely when closed. The door was closed several times by staff T in order to test the latching device and the door failed to latch securely with each attempt. This was also verified by staff J during tour.

Based on observation and staff verification during tour, it was determined this facility failed to ensure the patient room seclusion door locks operated properly in order to ensure the door could be opened readily in the event of an emergency. This had the potential to affect all those utilizing the seclusion rooms while the door locks were activated. The facility census at the beginning of the survey was 24.

Findings include:

Tour of the facility took place on 12/14/10 with staff members T and J. During tour of the facility, observation was made of two seclusion rooms located behind the medication room. Both seclusion rooms were noted to have doors equipped with three dead bolt locks mounted at the top, middle and bottom of the door. The top and bottom locks were thumb latch dead bolts and the middle lock was keyed. All locks were able to be activated and deactivated from only the outside of the door.
Staff J operated the keyed dead bolt lock of seclusion room number one and observation was made by this surveyor of staff J having a difficult time locking and unlocking the dead bolt. Concerted effort was made during at least a two minute period for staff J to deactivate the keyed dead bolt once it was activated. This surveyor attempted to activate the thumb latch dead bolts on the door of seclusion room number one and had much difficulty activating and deactivating them. Staff T stated they have not used these rooms as seclusion rooms for at least the past two years and the locks will have to be addressed.

Based on documentation review for the emergency battery operated lights and staff interview it was determined this facility failed to ensure the emergency battery operated lights were tested for the required 30 seconds each month and the 90 minute annual test. This had the potential to affect all those utilizing this facility. The facility census at the beginning of the survey was 24.

Findings include:

Documentation review for the emergency battery operated lights took place on 12/13/10. Observation was made of one 30 second monthly test which was performed this December. Request was made for any additional testing reports and staff T stated there were no additional reports available. Staff T also stated they had recently started to document the required monthly and annual testing of the battery operated emergency lights on a newly revised form.

Based on documentation review of smoke detector testing, staff interview and observation during tour it was determined this facility failed to ensure the proper placement of smoke detectors according to the National Fire Protection Association (NFPA) 72 Chapter 2-3.5.1 and failed to maintain documentation regarding the annual testing of smoke detectors including sensitivity testing. This had the potential to affect all those utilizing this facility. The facility census at the beginning of the survey was 24.

Findings include:

A request was made on 12/13/10 for the review of smoke detector testing documentation including sensitivity testing. Staff T stated no documentation was available at this time. Staff T stated this facility has recently initiated a plan to replace all smoke detectors with a new computerized self monitoring system which will enable continuous sensitivity testing of each smoke detector.
Additionally, tour of the facility took place on 12/14/10 with staff members T and J. During tour observation was made of smoke detectors which were mounted near air flow devices in the following areas:
*Within the maintenance shop room
*In the corridor near the east exit door of the 100 wing
*In the dayroom of the 100 wing
*At the exit door near the dayroom of the 200 wing
*Within the corridor outside of room 212 and 216

These findings were verified by staff T and J during tour on 12/14/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure the proper storage of medical gas cylinders within the medical gas storage location. This had the potential to affect all those utilizing this facility. The facility census at the beginning of the survey was 24.

Findings include:

Tour of the facility took place on 12/14/10 with staff T and J. Observation was made within the medical gas storage room of ten E tanks of oxygen, four of which were not secured or placed in a holding device. This finding was verified by staff T and J during tour.