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Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating . Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 2/10/2010 the surveyor noted penetrations of both the ceiling of the autoclave room and in the wall of the CT control room.

Based on observation the facility failed to provide doors that would resist the passage of smoke. Failure on the part of the facility to provide doors that have the ability to resist the passage of smoke puts patients, staff and visitors of the facility at risk of injury in the event of a fire.

Findings include:

1. On 2/9/2010 while touring the facility the surveyor noted that the respiratory therapy supply closet door located on the east corridor was not provide with positive latching hardware as required.

2. On 2/9/2010 while touring the facility the surveyor noted that the clean utility closet door located on the east corridor was not provide with positive latching hardware as required.

3. On 2/9/2010 while touring the facility the surveyor noted that the mammography office door located on the east corridor was not capable of resisting the passage of smoke due to the removal of a dead bolt mechanism.

4. On 2/10/2010 while touring the facility the surveyor noted that the cross corridor (east corridor) doors located by the nurses station failed to latch properly.

Based on observation the facility failed to provide functional emergency lighting equipment as required. Failure on the part of the facility to provide required emergency lighting equipment puts patients at risk of injury should there be a loss of primary lighting in those areas providing life support services.

Findings include:

1. On 2/10/2010 while touring the facility the surveyor noted that the battery system serving the emergency lighting fixture in the operating room did not function properly when the test button was pushed.

Based on staff interview the facility failed to provide staff who are adequately familiar by training with the facility's emergency procedures for fire. Failure on the part of the facility to have staff adequately trained to respond to a fire emergency puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. During a tour of the facility with the Deputy State Fire Marshal (DSFM) on 9/10/2010 the surveyor witnessed a member of the nursing staff responding to questions posed by the DSFM. When the nurse was asked were the nearest fire alarm pull station was located the individual was unable to give the correct response.

2. During a tour of the facility with the Deputy State Fire Marshal (DSFM) on 9/10/2010 the surveyor witnessed a member of the nursing staff responding to questions posed by the DSFM. When the nurse was asked to provide the emergency plan one was not immediately made available as its location was not known.

Based on observation the facility failed to provide continuity of smoke barriers in the facility and to maintain the building's interior fire resistance rating . Failure to provide smoke barrier continuity and maintaining the interior fire resistance rating puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. On 2/10/2010 the surveyor noted penetrations of both the ceiling of the autoclave room and in the wall of the CT control room.

Based on observation the facility failed to provide doors that would resist the passage of smoke. Failure on the part of the facility to provide doors that have the ability to resist the passage of smoke puts patients, staff and visitors of the facility at risk of injury in the event of a fire.

Findings include:

1. On 2/9/2010 while touring the facility the surveyor noted that the respiratory therapy supply closet door located on the east corridor was not provide with positive latching hardware as required.

2. On 2/9/2010 while touring the facility the surveyor noted that the clean utility closet door located on the east corridor was not provide with positive latching hardware as required.

3. On 2/9/2010 while touring the facility the surveyor noted that the mammography office door located on the east corridor was not capable of resisting the passage of smoke due to the removal of a dead bolt mechanism.

4. On 2/10/2010 while touring the facility the surveyor noted that the cross corridor (east corridor) doors located by the nurses station failed to latch properly.

Based on observation the facility failed to provide functional emergency lighting equipment as required. Failure on the part of the facility to provide required emergency lighting equipment puts patients at risk of injury should there be a loss of primary lighting in those areas providing life support services.

Findings include:

1. On 2/10/2010 while touring the facility the surveyor noted that the battery system serving the emergency lighting fixture in the operating room did not function properly when the test button was pushed.

Based on staff interview the facility failed to provide staff who are adequately familiar by training with the facility's emergency procedures for fire. Failure on the part of the facility to have staff adequately trained to respond to a fire emergency puts patients, staff and visitors of the facility at risk from the effects of smoke and fire.

Findings include:

1. During a tour of the facility with the Deputy State Fire Marshal (DSFM) on 9/10/2010 the surveyor witnessed a member of the nursing staff responding to questions posed by the DSFM. When the nurse was asked were the nearest fire alarm pull station was located the individual was unable to give the correct response.

2. During a tour of the facility with the Deputy State Fire Marshal (DSFM) on 9/10/2010 the surveyor witnessed a member of the nursing staff responding to questions posed by the DSFM. When the nurse was asked to provide the emergency plan one was not immediately made available as its location was not known.