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Based on observation and interview, it was determined the facility failed to maintain the fire door for the Soiled Linen Room to ensure the door was self-closing due to a missing closure arm on the fire door. The failed practice had the potential to affect the health and safety of all patients, staff, and visitors due to the potential spread of smoke and fire from the open door of the room if the door was not maintained in the closed position. The facility had a census of 11 patients on 06/19/12. The findings follow:

A. On a tour of the facility with the Maintenance Technician on 06/20/12 at 1330, the closure arm on fire door for the Soiled Linen Room located near Patient Room 108 was missing. The missing closure arm prevented the door from automatically closing as required.
B. The Maintenance Technician verified the missing closure arm at the time of the inspection of the Soiled Linen Room.

Based on observation and interview, it was determined the two of two fire doors for the exit stairs located on the west side of the facility were not maintained to ensure reliable exiting and prevent the infiltration of fire and smoke into the stairwell due to an improperly operating fire door and fire door propped open with a chair. The failed practice had the potential to affect the health and safety of all patients, staff, and visitors due the potential of delayed exiting and potential of infiltration of fire and smoke into the stairwell. The facility had a census of 11 patients on 06/19/12. The findings follow:

On a tour of the facility on 06/20/12 at 1410 with the Maintenance Technician, the following observations were made:
A. The fire door at the discharge from the stairwell to the exterior of the building was jammed and could only be opened with excessive force. The door was also missing a self-closing device.
B. The interior fire door from the corridor into the stairwell was propped open with a chair, which prevented the door from automatically closing.
C. The Maintenance Technician verified the condition of the exterior fire door and the propped open interior fire door of the stairwell at the time of the inspection of the exit stairs.

Based on Backup Emergency Lights maintenance record review and interview, it was determined the facility did not perform the required monthly 30 second battery test and annual 1 ? hour battery test on 11 of 11 battery powered emergency lights as required by NFPA 101 Section 7.9.3 for the years 2011 and 2012. Failure to perform the required testing of the emergency light fixture prevented the facility from ensuring the reliability of the emergency light fixture illuminate the emergency egress in the event of a loss of normal power. The failed practice had the potential to affect all patients, staff, and visitors. The facility had a census of 11 patients on 06/19/12. The findings follow:

A. Review of Backup Emergency Lights maintenance record for the years 2011 and 2012 on 06/19/12 at 1020 revealed there was no documentation of monthly or annual testing of emergency light fixtures batteries.
B. In an interview on 06/19/12 at 1500, the Maintenance Technician verified battery testing was not a part of the emergency light testing and there was no further documentation available for review.

Based Exit Light Check maintenance record review and interview, it was determined the facility did not perform the required monthly 30 second battery test and annual 1 ? hour battery test on 11 of 11 battery powered emergency lights as required by NFPA 101 Section 7.10.9.2 for the years 2011 and 2012. Failure to perform the required testing of the exit light fixtures prevented the facility from ensuring the reliability of the exit lights to indicate the location of emergency exits in the event of a loss of normal power. The failed practice had the potential to affect all patients, staff, and visitors. The facility had a census of 11 patients on 06/19/12. The findings follow:

A. Review of the Exit Light Checks maintenance record for the years 2011 and 2012 on 06/19/12 at 1020 revealed there was no documentation of monthly or annual testing of exit sign batteries.
B. In an interview on 06/19/12 at 1500, the Maintenance Technician verified battery testing was not a part of the exit sign testing and there was no further documentation available for review.