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Based on observation and interview, it was determined the facility did not maintain walls and ceilings in the surgical suite and kitchen in a good state of repair. The failed practice had the potential to affect the health and safety of patients due to the potential of contamination of canned goods and food preparation areas in the kitchen and the inability to properly clean the affected walls and ceilings in the surgical suite. The failed practice had the potential to affect three of three patients in the facility on 06/27/11 and all staff, visitors, and patients admitted to the facility. The facility had an average census of 3.8 patients a month. The findings follow:

A. On a tour of the surgical suite on 06/28/11 at 1015, the wall in the Clean Scope Room had cracked and peeling paint. The ceiling in the surgical corridor outside Surgery 1 was cracked. The QA/PI (Quality Assessment/Process Improvement) Coordinator verified the damaged areas at the time of observation.
B. On a tour of the facility on 06/28/11 at 1300 with the Director of Maintenance, the following observation were made:
1) In the Dry Goods Storage Room in the kitchen, a section of the ceiling was damaged with exposed rusted metal mesh. The damaged area was located directly over canned goods. Director of Maintenance stated there had been a water leak at this location.
2) A bucket was observed on the floor with water periodically dripping into it. The bucket was located under a ceiling grille with water dripping off of the grille into the bucket. The Director of Maintenance stated the area had periodic problems in the past with roof leaks at this location but he thought it had been repaired.

Based on inspection report review, observation, and interview, it was determined the facility did not meet Life Safety Code requirements related to fire alarm system inspections, generator load testing, fire drills, line isolation monitor testing, storage of combustible materials, the use of door wedges to hold open fire doors. The failed practice had the potential to affect three of three patients in the facility on 06/27/11 and all staff, visitors, and patients admitted to the facility. The facility had an average census of 3.8 patients a month. See Tags K21, K29, K50, K52, K130, and K144. The failed practices had the following outcomes:
A. Failure to conduct fire drills has the potential to affect the safety of all building occupants because the affectiveness of the fire plan and staff training in the event of a fire event cannot be evaluated.
B. Failure to inspect the fire alarm system had the potential to affect the health and safety of patients because the reliability of the fire alarm system could not be assured.
C. Failure to inspect and exercise the generator as required has the potential to affect the health and safety of patients because the reliability of the generators to supply electrical power to the facility in the event of the loss of normal power was not evaluated and could not be assured.
D. Failure to test the line isolation monitors had the potential to affect the health and safety of surgical patients because the proper function of the monitors to prevent electric shock was not evaluated.
E. The use of door wedges on fire doors has the potential to affect the health and safety of all patients and building occupants because the wedges prevent the fire doors from automatically closing in the event of a fire, allowing passage of fire and smoke from one smoke compartment to another.
F. Storage of combustible materials in an unprotected room has the potential to affect the health and safety of surgery patients in the area due to the potential spread of fire and smoke beyond the storage room into the surgical suite.

Based on interview, it was determined a current roster of surgical privileges for each physician was not maintained in the Operating Room areas. Failure to have each physician's approved surgical procedures available in the Operating Room areas did not afford the Operating Room staff the ability to ensure physicians only performed procedures they were approved for. The failed practice had the potential to affect all patients who receive surgery at the facility. Findings follow:

A. The Quality Assurance/Process Improvement (QA/PI) Coordinator was asked for the current roster of surgical privileges for each physician during the tour on 06/28/11 at 1035.
B. The Director of Nursing and the QA/PI Coordinator both verified during an interview on 06/28/11 at 1345 that current surgical privileges for each physician were not maintained in the Operating Room.