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Based on observation and interview the facility failed to assure all patient room doors would close tightly in the door frame when the door was closed. The facility census was nine.

Findings included:

A tour of the facility, conducted on the afternoon of 11/09/10, revealed the door latch to patient room 149 would not work properly and would not keep the door closed.

Staff K, Quality Improvement, confirmed at that time the door latch was not working properly.

Based on record review and interview the facility failed to inspect, test and maintain the sprinkler system in accordance with National Fire Protection Association 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. The facility census was nine.

Findings included:

Review of the facility sprinkler system inspection reports, conducted on the morning of 11/09/10, showed the last documented inspection of the sprinkler system was on 12/08/09. Staff U Physical Plant Director, when questioned at 11:05 AM on 11/09/10, confirmed that quarterly inspections of the sprinkler system were not currently being conducted.

Based on interview the facility failed to develop a procedure to implement any time the facility sprinkler system is non operational for more than 4 hours. The facility census was nine.

Findings included:

During an interview, conducted at 11:05 AM on 11/09/10, Staff U Physical Plant Director stated the facility did not have a procedure to implement if the facility sprinkler system were to be non operational for more than 4 hours in a 24 hour time frame.

Based on interview the facility failed to develop a procedure to implement any time the facility fire alarm system in non operational for more than 4 hours. The facility census was nine.

Findings included:

During an interview, conducted at 11:05 AM on 11/09/10, Staff U Physical Plant Director stated the facility did not have a procedure to implement if the facility fire alarm system were to be non operational for more than 4 hours in a 24 hour time frame.

Based on observation the facility failed to install an Alcohol Based Hand Rub dispenser in a location away from an ignition source. The facility census was nine.

Findings included:

Observation on 11/09/10 at 3:35 PM showed an alcohol based hand rub dispenser mounted to the wall just above an electrical light switch in the corridor by the double doors to the patient room area from the main entrance. This dispenser contained 7 ounces of 62% Ethyl Alcohol Waterless Antimicrobial Foaming Hand Rub.

Observation on 11/10/10 at 2:40 PM showed an alcohol based hand rub dispenser mounted to the wall just above an electrical light switch in the facility X-ray room. This dispenser contained 7 ounces of 62% Ethyl Alcohol Waterless Antimicrobial Foaming Hand Rub.

Based on observation and interview the facility failed to assure all patient room doors would close tightly in the door frame when the door was closed. The facility census was nine.

Findings included:

A tour of the facility, conducted on the afternoon of 11/09/10, revealed the door latch to patient room 149 would not work properly and would not keep the door closed.

Staff K, Quality Improvement, confirmed at that time the door latch was not working properly.

Based on record review and interview the facility failed to inspect, test and maintain the sprinkler system in accordance with National Fire Protection Association 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. The facility census was nine.

Findings included:

Review of the facility sprinkler system inspection reports, conducted on the morning of 11/09/10, showed the last documented inspection of the sprinkler system was on 12/08/09. Staff U Physical Plant Director, when questioned at 11:05 AM on 11/09/10, confirmed that quarterly inspections of the sprinkler system were not currently being conducted.

Based on interview the facility failed to develop a procedure to implement any time the facility sprinkler system is non operational for more than 4 hours. The facility census was nine.

Findings included:

During an interview, conducted at 11:05 AM on 11/09/10, Staff U Physical Plant Director stated the facility did not have a procedure to implement if the facility sprinkler system were to be non operational for more than 4 hours in a 24 hour time frame.

Based on interview the facility failed to develop a procedure to implement any time the facility fire alarm system in non operational for more than 4 hours. The facility census was nine.

Findings included:

During an interview, conducted at 11:05 AM on 11/09/10, Staff U Physical Plant Director stated the facility did not have a procedure to implement if the facility fire alarm system were to be non operational for more than 4 hours in a 24 hour time frame.