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Based on observation, testing, interview, and document review, the provider failed to ensure corrective measures outlined in the plan of correction with a correction date of 4/16/10 from the 3/23/10 recertification survey were completed. Four randomly observed room doors (the former pediatric room, room 114, computer room, and laundry room) had locking hardware that prevented the door from being opened in an emergency. Findings include:

1. Random observation from 9:00 a.m. to 3:00 p.m. on 6/30/10 revealed:
* The door for the former pediatric room had a deadbolt locking mechanism (photo 1). That deadbolt locking mechanism would impede opening the doors in a fire emergency.
* The doors for room 114 (photo 3), the computer room, and laundry room between the soiled and clean area had double-action latching hardware. The double-action hardware would impede opening the doors in a fire emergency.

Interview with the maintenance supervisor (MS) at 3:00 p.m. on that same day revealed he was not aware the door hardware had not been installed or removed from the above listed rooms. He stated he and the maintenance assistant had split the work from the former survey. He was not aware what had and had not been completed. He stated he had not seen the plan of correction for the life safety code survey and was unaware of all the items that were listed.

Interview with the maintenance assistant (MA) at 9:30 a.m. on 6/29/10 revealed he had maintained checklists. Review of the quality assurance (QA) checklists revealed they had been completed for April, May, and June 2010. The only life safety code items noted on that QA checklist were: inspect all fire extinguishers and tags, monthly fire drills, and no extension cords or power strips. The weekly, monthly, and quarterly checklists had no items that related to the citations listed on the prior survey conducted on 3/23/10. The MA revealed he had not completed all the checklists and had not reported to QA quality improvement (QI) monthly regarding the checklists or completion of the citations noted on the prior survey. Continued interview with the MA at that time revealed he had not seen the plan of correction for the life safety code survey and was unaware of all the items that were listed.

Interview with the director of nursing and nurse consultant at 3:45 p.m. on 6/30/10 revealed they were unaware the maintenance department had not corrected and/or completed their portion of the citations from the life safety code survey. Continued interview with the QAQI coordinator revealed she had received no reports from the maintenance department regarding the life safety code survey. She stated she had not received a report from the maintenance department regarding any documentation or activities for months.

Interview with the administrator at 11:30 a.m. on 7/1/10 revealed he was not aware the life safety code citations had not been completed from the life safety code recertification survey. He stated he had not kept himself current on the status of the completion of the corrections and had relied on the MS and assistant to have the citations completed by the given deadline.

Based on observation, interview, and document review, the provider failed to ensure corrective measures outlined in the plan of correction with a correction date of 4/16/10 from the 3/23/10 recertification survey were completed. The provider failed to maintain adequate illumination of the means of egress in the south exit stair enclosure. Only one lamp was working in the fixture at the top of the stair enclosure. Findings include:

1. Observation at 10:00 a.m. on 6/30/10 revealed the light fixture at the top of the exit stair enclosure had one of two light bulbs illuminated (photo 4). That area would be left in darkness in an egress emergency if the remaining operating bulb failed. Interview with the maintenance supervisor (MS) at the time of the observation confirmed a bulb had not been replaced in that light fixture. He confirmed he was aware the problem had been identified on the last survey.

Interview with the maintenance assistant (MA) at 9:30 a.m. on 6/29/10 revealed he had maintained checklists. Review of the quality assurance (QA) checklists revealed they had been completed for April, May, and June 2010. The only life safety code items noted on that QA checklist were: inspect all fire extinguishers and tags, monthly fire drills, and no extension cords or power strips. The weekly, monthly, and quarterly checklists had no items that related to the citations listed on the prior survey conducted on 3/23/10. The MA revealed he had not completed all the checklists and had not reported to QA quality improvement (QI) monthly regarding the checklists or completion of the citations noted on the prior survey. Continued interview with the MA at that time revealed he had not seen the plan of correction for the life safety code survey and was unaware of all the items that were listed.

Interview with the director of nursing and nurse consultant at 3:45 p.m. on 6/30/10 revealed they were unaware the maintenance department had not corrected and/or completed their portion of the citations from the life safety code survey. Interview with the QAQI coordinator at that same time revealed she had received no reports from the maintenance department regarding the life safety code survey. She stated she had not received a report from the maintenance department regarding any documentation or activities for months.


Interview with the administrator at 11:30 a.m. on 7/1/10 revealed he was not aware the life safety code citations had not been completed from the recertification survey. He stated he had not kept himself current on the status of the completion of the citations and had relied on the MS and assistant to have the corrections completed by the given deadline

Based on document review and interview, the provider failed to ensure corrective measures outlined in the plan of correction with a correction date of 5/8/10 from the 3/23/10 recertification survey were completed. The provider failed to perform fire drills monthly and hold mandatory fire drill education for all staff. Findings include:

1. Document review of past fire drills since the 3/23/10 survey revealed a fire drill had not been conducted since 2/15/10. No documentation or training verification for the mandatory fire drill education held 4/23/10 could be located.

Interview with the maintenance supervisor (MS) at 2:00 p.m. on 6/30/10 confirmed the above findings. He stated he had been told by the maintenance assistant (MA) who kept the records monthly fire drills were not needed for the facility. The MS revealed he had not completed the mandatory fire drill education training.

Interview with the MA at 9:30 a.m. on 6/29/10 revealed he had maintained checklists. Review of the quality assurance (QA) checklists revealed they had been completed for April, May, and June 2010. The only life safety code items noted on that QA checklist were: inspect all fire extinguishers and tags, monthly fire drills, and no extension cords or power strips. The weekly, monthly, and quarterly checklists had no items that related to the citations listed on the prior survey conducted on 3/23/10. The MA revealed he had not completed all the checklists and had not reported to QA quality improvement (QI) monthly regarding the checklists or completion of the citations noted on the prior survey. Continued interview with the MA at that time revealed he had not seen the plan of correction for the life safety code survey and was unaware of all the items that were listed.

Continued interview with the MA at 3:00 p.m. on 6/30/10 revealed he was not aware a monthly fire drill must be completed for the facility. He was also not aware the fire drill education had not been completed.

Interview with the director of nursing and nurse consultant at 3:45 p.m. on 6/30/10 revealed they were unaware the maintenance department had not corrected and/or completed their portion of the citations from the life safety code survey. Interview with the QAQI coordinator at that same time revealed she had received no reports from the maintenance department regarding the life safety code survey. She stated she had not received a report from the maintenance department regarding any documentation or activities for months.

Interview with the administrator at 11:30 a.m. on 7/1/10 revealed he was not aware the life safety code citations had not been completed from the life safety code recertification survey. He stated he had not kept himself current on the status of the completion of the corrections and had relied on the MS and assistant to have the citations completed by the given deadline.

Based on observation, document review, and interview, the provider failed to ensure corrective measures outlined in the plan of correction with a correction date of 4/26/10 from the 3/23/10 recertification survey were completed. The provider failed to perform monthly checks of fire extinguishers in the computer room and the boiler room. Findings include:

1. Observation at 10:30 a.m. on 6/30/10 revealed two fire extinguishers did not have monthly maintenance checks written on the tags. The extinguisher in the computer room had not been checked since October 2009 (photo 8). The extinguisher in the boiler room had no tag to verify the extinguisher had been inspected monthly (photo 7).

Interview with the maintenance supervisor (MS) at 1:30 p.m. on 6/30/10 revealed he was not aware those extinguishers had not been checked. He was not aware of any other verification to ensure the extinguishers had been checked monthly except for the tag on the extinguisher. The MS revealed he was not aware the extinguisher in the boiler room did not have a an inspection tag. He stated he and the maintenance assistant had split the work from the former survey, and he was not aware what had and had not been completed.

Interview with the maintenance assistant (MA) at 9:30 a.m. on 6/29/10 revealed he had maintained checklists. Review of the quality assurance (QA) checklists revealed they had been completed for April, May, and June 2010. The only life safety code items noted on that QA checklist were: inspect all fire extinguishers and tags, monthly fire drills, and no extension cords or power strips. The weekly, monthly, and quarterly checklists had no items that related to the citations listed on the prior survey conducted on 3/23/10. The MA revealed he had not completed all the checklists and had not reported to QA quality improvement (QI) monthly regarding the checklists or completion of the citations noted on the prior survey. Continued interview with the MA at that time revealed he had not seen the plan of correction for the life safety code survey and was unaware of all the items that were listed.

Interview with the director of nursing and nurse consultant at 3:45 p.m. on 6/30/10 revealed they were unaware the maintenance department had not corrected and/or completed their portion of the citations from the life safety code survey. Interview with the QAQI coordinator at that same time revealed she had received no reports from the maintenance department regarding the life safety code survey. She stated she had not received a report from the maintenance department regarding any documentation or activities for months.

Interview with the administrator at 11:30 a.m. on 7/1/10 revealed he was not aware the life safety code citations had not been completed from the life safety code recertification survey. He stated he had not kept himself current on the status of the completion of the corrections and had relied on the MS and assistant to have the citations completed by the given deadline.

Based on observation, interview, and document review, the provider failed to ensure corrective measures outlined in the plan of correction with a correction date of 5/8/10 from the 3/23/10 recertification survey were completed. The provider failed to ensure the safety of occupants from possible burns and/or fire. A portable space heater was located in the pharmacy. Findings include:

1. Observation at 3:30 p.m. on 6/28/10 revealed a milk house style portable space heater was located in pharmacy. Interview with the maintenance supervisor at the time of the observation confirmed that finding. He stated the pharmacy technician probably used that space heater. He revealed he was unaware no one had removed the space heater but was aware it was a prior citation on the previous survey.

Interview with the maintenance assistant (MA) at 9:30 a.m. on 6/29/10 revealed he had maintained checklists. Review of the quality assurance (QA) checklists revealed they had been completed for April, May, and June 2010. The only life safety code items noted on that QA checklist were: inspect all fire extinguishers and tags, monthly fire drills, and no extension cords or power strips. The weekly, monthly, and quarterly checklists had no items that related to the citations listed on the prior survey conducted on 3/23/10. The MA revealed he had not completed all the checklists and had not reported to QA quality improvement (QI) monthly regarding the checklists or completion of the citations noted on the prior survey. Continued interview with the MA at that time revealed he had not seen the plan of correction for the life safety code survey and was unaware of all the items that were listed.

Interview with the director of nursing and nurse consultant at 3:45 p.m. on 6/30/10 revealed they were unaware the maintenance department had not corrected and/or completed their portion of the citations from the life safety code survey. Interview with the QAQI coordinator at that same time revealed she had received no reports from the maintenance department regarding the life safety code survey. She stated she had not received a report from the maintenance department regarding any documentation or activities for months.

Interview with the administrator at 11:30 a.m. on 7/1/10 revealed he was not aware the life safety code citations had not been completed from the life safety code recertification survey. He stated he had not kept himself current on the status of the completion of the corrections and had relied on the MS and assistant to have the citations completed by the given deadline.

Based on observation, testing, interview, and document review, the provider failed to ensure corrective measures outlined in the plan of correction with a correction date of 5/8/10 from the 3/23/10 recertification survey were completed. Multiple tap adaptors were in-use in the admissions office and in patient room 106. An extension cord and power strip were found in-use in the maintenance office. Findings include:

1. Observation at 3:20 p.m. on 6/28/10 revealed a multiple tap adapter in patient room 106. Additional observation at 3:25 p.m. on that same day revealed a multiple tap adapter in-use in the admissions office (photo 2). Interview with the maintenance supervisor (MS) at the time of the observations confirmed those findings.

2. Observation at 11:25 a.m. on 6/29/10 revealed an extension cord affixed to the ceiling in the maintenance office. That extension cord was used to power a fluorescent light fixture (photo 5). Continued observation at that time revealed a power strip attached to the west wall in use to charge tools (photo 6). Interview with the maintenance assistant at the time of the observation confirmed those findings. He stated he was not aware of the extension cord in the ceiling. He stated he had removed the carbon monoxide detector from the power strip but was not aware the power strip itself was a citation.

Interview with the maintenance assistant (MA) at 9:30 a.m. on 6/29/10 revealed he had maintained checklists. Review of the quality assurance (QA) checklists revealed they had been completed for April, May, and June 2010. The only life safety code items noted on that QA checklist were: inspect all fire extinguishers and tags, monthly fire drills, and no extension cords or power strips. The weekly, monthly, and quarterly checklists had no items that related to the citations listed on the prior survey conducted on 3/23/10. The MA revealed he had not completed all the checklists and had not reported to QA quality improvement (QI) monthly regarding the checklists or completion of the citations noted on the prior survey. Continued interview with the MA at that time revealed he had not seen the plan of correction for the life safety code survey and was unaware of all the items that were listed.

Interview with the director of nursing and nurse consultant at 3:45 p.m. on 6/30/10 revealed they were unaware the maintenance department had not corrected and/or completed their portion of the citations from the life safety code survey. Interview with the QAQI coordinator at that same time revealed she had received no reports from the maintenance department regarding the life safety code survey. She stated she had not received a report from the maintenance department regarding any documentation or activities for months.

Interview with the administrator at 11:30 a.m. on 7/1/10 revealed he was not aware the life safety code citations had not been completed from the life safety code recertification survey. He stated he had not kept himself current on the status of the completion of the corrections and had relied on the MS and assistant to have the citations completed by the given deadline