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Based on observation and staff interview, the facility failed to provide doors protecting corridor openings with positive latching hardware in 1 of 5 smoke compartments. This condition had the potential to allow smoke and fire to migrate into the Central Exit Corridor. Facility census was 7 of 20.

Findings are:
Observation during the facility tour on 4/1/12, at 11:38 am revealed the sliding corridor doors to Observation Rooms 1-8 opened to the exit corridor and failed to have positive latching devices installed in the room doors. The facility failed to provide smoke resistive doors, or meet the requirements of a suite.
In an interview conducted at the time of observation, (4/1/12, at 11:38 am), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to mark the means of egress so that exits were readily apparent to occupants in 1 of 5 smoke compartments. This condition had the potential for occupants to not be able to find an exit in an emergency near the Patient Safety Office. Facility census was 7 of 20.

Findings are:
Observation during the facility tour on 4/18/12, at 11:16 am revealed that the facility failed to have readily visible exit signs installed when standing outside the Patient Safety Office.
In an interview conducted at the time of observation, (4/18/12, at 11:16 am), Maintenance A confirmed that exit signage was not readily visible.

Based on observation and staff interview, the facility failed to provide separation of a hazardous area from other compartments in 1 of 5 smoke compartments. This condition had the potential for the IT Room/Office Door to be left open after suppression system activation, which would prevent the suppression of a fire. Facility census was 7 of 20.

Findings are:
Observations during the facility tour on 4/18/12, at 12:14 pm revealed the IT Room/Office Door failed to have a self-closure installed on the door, which separated an office from the IT Room that contained a clean agent suppression system.
In an interview conducted at the time of observation, (4/18/12, at 12:14 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to arrange a corridor so that it would not have a dead end over 30 feet in 1 of 5 smoke compartments. This condition had the potential to allow occupants to become trapped during a fire in the Corridor by the Conference Room. Facility census was 7 of 20.

Findings are:
Observations during the facility tour on 4/18/12, at 11:58 am revealed:
1. Observation of the exiting corridor by the Conference Room revealed the corridor failed to have an exit. Counting the ceiling tiles for the corridor revealed the corridor created an approximate 52 foot dead-end. The corridor led to a door into the old ER Garage/Storage Room. The openings in this corridor led to the Conference Room and into the two hour separated Medical Clinic.
2. The staff used the old ER Garage/Storage Room for an exit access to reach the outside exit located in the room. This required passing through a hazardous storage area with no separation.
In an interview conducted at the time of observation, (4/18/12, at 11:58 am), Maintenance A confirmed the exit arrangement.

Based on observation and staff interview, the facility failed to provide a new exit door of at least 41.5 inches wide in 1 of 5 smoke compartments. This condition had the potential to prevent the evacuation of occupants due to the width restriction in the 200 Wing. Facility census was 7 of 20.

Findings are:
Observation during the facility tour on 4/18/12, at 11:01 am revealed the facility failed to install a new exit door from the 200 Wing of at least 41.5 inches in clear width. The door was a 36 inch door.
In an interview conducted at the time of observation, (4/18/12, at 11:01 am), Maintenance A confirmed the size of the door.

Based on observation and staff interview, the facility failed to provide battery backup task illumination in the Operating Room. This condition had the potential to leave occupants in darkness during the 1-10 second gap before the emergency generator restored lighting to the Operating Room. Facility census was 7 of 20.

Findings are:
Observation during the facility tour on 4/18/12, at 11:48 am revealed the Operating Room failed to have a battery backup emergency light for task illumination.
In an interview conducted at the time of observation, (4/18/12, at 11:48 am), Maintenance A confirmed that the light had not been installed yet due scheduling conflicts with the electrician.

Actual NFPA Standard:
Actual NFPA Standard:
NFPA 99, 3-3.2.1.2.5e Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association, 70. This condition had the potential to cause an electrical fire. Facility census was 7 of 20.

Findings are:
Observation during the facility tour on 4/18/12, from 12:11 pm to 12:41 pm revealed:
1. Two power strips plugged into one power strip in the IT Room behind the Patch Panels. The facility failed to plug the power strips directly into a wall outlet.
2. The facility failed to mount the power strip in the PT Storage so the power strip did not hang by the cords, and cause mechanical damage to the cords.
In an interview conducted at the time of observation (6/22/11, at 11:08 am), Maintenance A acknowledged the use of the electrical equipment.

Based on observation and staff interview, the facility failed to provide doors protecting corridor openings with positive latching hardware in 1 of 5 smoke compartments. This condition had the potential to allow smoke and fire to migrate into the Central Exit Corridor. Facility census was 7 of 20.

Findings are:
Observation during the facility tour on 4/1/12, at 11:38 am revealed the sliding corridor doors to Observation Rooms 1-8 opened to the exit corridor and failed to have positive latching devices installed in the room doors. The facility failed to provide smoke resistive doors, or meet the requirements of a suite.
In an interview conducted at the time of observation, (4/1/12, at 11:38 am), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to mark the means of egress so that exits were readily apparent to occupants in 1 of 5 smoke compartments. This condition had the potential for occupants to not be able to find an exit in an emergency near the Patient Safety Office. Facility census was 7 of 20.

Findings are:
Observation during the facility tour on 4/18/12, at 11:16 am revealed that the facility failed to have readily visible exit signs installed when standing outside the Patient Safety Office.
In an interview conducted at the time of observation, (4/18/12, at 11:16 am), Maintenance A confirmed that exit signage was not readily visible.

Based on observation and staff interview, the facility failed to provide separation of a hazardous area from other compartments in 1 of 5 smoke compartments. This condition had the potential for the IT Room/Office Door to be left open after suppression system activation, which would prevent the suppression of a fire. Facility census was 7 of 20.

Findings are:
Observations during the facility tour on 4/18/12, at 12:14 pm revealed the IT Room/Office Door failed to have a self-closure installed on the door, which separated an office from the IT Room that contained a clean agent suppression system.
In an interview conducted at the time of observation, (4/18/12, at 12:14 pm), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to arrange a corridor so that it would not have a dead end over 30 feet in 1 of 5 smoke compartments. This condition had the potential to allow occupants to become trapped during a fire in the Corridor by the Conference Room. Facility census was 7 of 20.

Findings are:
Observations during the facility tour on 4/18/12, at 11:58 am revealed:
1. Observation of the exiting corridor by the Conference Room revealed the corridor failed to have an exit. Counting the ceiling tiles for the corridor revealed the corridor created an approximate 52 foot dead-end. The corridor led to a door into the old ER Garage/Storage Room. The openings in this corridor led to the Conference Room and into the two hour separated Medical Clinic.
2. The staff used the old ER Garage/Storage Room for an exit access to reach the outside exit located in the room. This required passing through a hazardous storage area with no separation.
In an interview conducted at the time of observation, (4/18/12, at 11:58 am), Maintenance A confirmed the exit arrangement.

Based on observation and staff interview, the facility failed to provide a new exit door of at least 41.5 inches wide in 1 of 5 smoke compartments. This condition had the potential to prevent the evacuation of occupants due to the width restriction in the 200 Wing. Facility census was 7 of 20.

Findings are:
Observation during the facility tour on 4/18/12, at 11:01 am revealed the facility failed to install a new exit door from the 200 Wing of at least 41.5 inches in clear width. The door was a 36 inch door.
In an interview conducted at the time of observation, (4/18/12, at 11:01 am), Maintenance A confirmed the size of the door.

Based on observation and staff interview, the facility failed to provide battery backup task illumination in the Operating Room. This condition had the potential to leave occupants in darkness during the 1-10 second gap before the emergency generator restored lighting to the Operating Room. Facility census was 7 of 20.

Findings are:
Observation during the facility tour on 4/18/12, at 11:48 am revealed the Operating Room failed to have a battery backup emergency light for task illumination.
In an interview conducted at the time of observation, (4/18/12, at 11:48 am), Maintenance A confirmed that the light had not been installed yet due scheduling conflicts with the electrician.

Actual NFPA Standard:
Actual NFPA Standard:
NFPA 99, 3-3.2.1.2.5e Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association, 70. This condition had the potential to cause an electrical fire. Facility census was 7 of 20.

Findings are:
Observation during the facility tour on 4/18/12, from 12:11 pm to 12:41 pm revealed:
1. Two power strips plugged into one power strip in the IT Room behind the Patch Panels. The facility failed to plug the power strips directly into a wall outlet.
2. The facility failed to mount the power strip in the PT Storage so the power strip did not hang by the cords, and cause mechanical damage to the cords.
In an interview conducted at the time of observation (6/22/11, at 11:08 am), Maintenance A acknowledged the use of the electrical equipment.