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Based on observation and interview with facility staff, the facility failed to maintain 1 of 7 smoke separation door openings. Failure to maintain the smoke separation door put patients and staff at risk during a fire due to the spread of smoke. The facility census was 14
.
Findings are:

During the survey on 01-13-16 at 11:35 am, observation through testing revealed the smoke separation door into the east patient corridor would not close due to malfunction of the latching system of the door.
Interview on 01-13-16 at 11:35 am, with Maintenance " A " verified the door did not close all the way in its frame.

Based on observation and interview the facility failed to provide clear and unobstructed exits from the facility. This deficient practice could affect the evacuation of patients in surgery and the staff in the business offices. The facility census was 14.

Findings are:

Observation on 01-13-16 at 10:05 AM., of the North Surgery Corridor, revealed empty boxes being stored in the Corridor.
Interview on 01-13-16 at 10:05 AM with Maintenance " A " confirmed the storage of boxes in the corridor.

Based on record review and interview, the facility failed to adequately document and hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. This had the potential to affect staff preparation and experience in providing for the protection of all patients in the event of a fire. The facility census was 14

Findings are:

Record review on 01-13-16 at 10:35 AM of fire drill documentation showed that the facility had failed to conduct a fire drill for the 3-11 shift in the fourth quarter. Each shift had some drills less than an hour difference from the previous ones.

Interview on 01-13-16 at 10:35 am with Maintenance " A " confirmed the observations and findings.


Record review of the following NFPA Standard revealed: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 18/19.7.1.2

Based on observation and interview with facility staff, the facility failed to maintain 1 of 7 smoke separation door openings. Failure to maintain the smoke separation door put patients and staff at risk during a fire due to the spread of smoke. The facility census was 14
.
Findings are:

During the survey on 01-13-16 at 11:35 am, observation through testing revealed the smoke separation door into the east patient corridor would not close due to malfunction of the latching system of the door.
Interview on 01-13-16 at 11:35 am, with Maintenance " A " verified the door did not close all the way in its frame.

Based on observation and interview the facility failed to provide clear and unobstructed exits from the facility. This deficient practice could affect the evacuation of patients in surgery and the staff in the business offices. The facility census was 14.

Findings are:

Observation on 01-13-16 at 10:05 AM., of the North Surgery Corridor, revealed empty boxes being stored in the Corridor.
Interview on 01-13-16 at 10:05 AM with Maintenance " A " confirmed the storage of boxes in the corridor.

Based on record review and interview, the facility failed to adequately document and hold fire drills under varied conditions at different times of the day for four of four quarters reviewed. This had the potential to affect staff preparation and experience in providing for the protection of all patients in the event of a fire. The facility census was 14

Findings are:

Record review on 01-13-16 at 10:35 AM of fire drill documentation showed that the facility had failed to conduct a fire drill for the 3-11 shift in the fourth quarter. Each shift had some drills less than an hour difference from the previous ones.

Interview on 01-13-16 at 10:35 am with Maintenance " A " confirmed the observations and findings.


Record review of the following NFPA Standard revealed: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 18/19.7.1.2