HospitalInspections.org

Based on observation and interview, the facility failed to maintain a two hour fire protective construction between itself and a nonconforming building (a medical office building). This has the potential to affect all patients at the facility. The facility census was eight patients.

Findings include:

On 10/21/15 at 9:15 AM a tour was taken of the facility with Staff Q.

1.On 10/21/15 at 9:15 AM observation of the double doors in the two hour barrier in the corridor that leads to the medical office building revealed the doors had a coordinator and latching hardware that did not coordinate and latch the double doors.

On 10/21/15 at 9:15 AM in an interview, Staff Q confirmed the finding.

2. On 10/21/15 at 9:20 AM observation above the drop down ceiling of the two hour barrier between the facility and the medical office building, as seen from the hospital side, revealed a six inch water line, a turquoise snorkel tube, and a salmon colored line each with annular spaces.

On 10/21/15 at 9:20 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure corridor doors with self closing and latching hardware closed and latched the doors. This has the potential to affect all eight patients at the facility.

Findings include:

On 10/19/15 at 3:10 PM a tour was conducted of the facility with Staff Q.

1.On 10/19/15 at 3:10 PM observation of the double doors between the education room and the corridor revealed it had self closing and latching hardware that when tested did not close and latch the doors.

On 10/19/15 at 3:10 PM in an interview, Staff Q confirmed the finding.

2. On 10/19/15 at 3:48 PM observation of the door between the corridor and the men ' s bathroom by the education room revealed it had self closing and latching hardware that did not self close and latch the door.

On 10/19/15 at 3:48 PM in an interview, Staff Q confirmed the finding.

3. On 10/19/15 at 3:55 PM observation of corridor room on room 131 revealed a chair in the room stopped the door from being closed.

On 10/19/15 at 3:55 PM in an interview, Staff Q confirmed the finding.

On 10/21/15 at 9:15 AM a tour was taken of the facility with Staff Q.

4. On 10/21/15 at 3:30 PM observation of the corridor door to the janitor closet revealed it had self closing and latching hardware that did not close and latch the door.

On 10/21/15 at 3:30 PM in an interview, Staff Q confirmed the finding.

Based on observation, interview, and review of the life safety code drawings revealed the facility failed to maintain the rating on its barriers. This has the potential to affect all eight patients at the facility.

Findings include:

On 10/20/15 at 9:50 AM a tour of the facility was taken with Staff Q.

1.On 10/20/15 at 10:30 AM observation of the one hour barrier over the double doors leading to the operating room corridor revealed an open one inch conduit holding three white and one red wire.

On 10/20/15 at 10:30 AM in an interview, Staff Q confirmed the finding.

2. On 10/20/15 at 10:32 AM observation of the same double doors in the one hour barrier revealed a quarter inch gap through the astragal and around the latching hardware. In addition, the doors were not on a coordinator so that when tested, if the door with the astragal closed first, the doors the latching hardware could not work and the doors would not close.

On 10/20/15 at 10:32 AM in an interview, Staff Q confirmed the finding.

3. On 10/20/15 at 10:45 AM observation above the drop down ceiling of the one hour barrier over the double doors leading to the surgery (on left) and radiology (on right) corridor revealed a two inch open conduit holding yellow wires and a three inch open conduit holding yellow lines.

On 10/20/15 at 10:45 AM in an interview, Staff Q confirmed the finding.

4. On 10/20/15 at 11:07 AM observation of the south one hour barrier in the radiologist office revealed a one inch penetration holding a grey wire.

On 10/20/15 at 11:07 AM in an interview, Staff Q confirmed the finding.

5. On 10/20/15 at 11:10 AM observation of the other side of the wall in the communication room revealed a one inch wide by six inch long square cut from the communication room-side dry wall.

On 10/20/15 at 11:10 AM in an interview, Staff Q confirmed the finding.

6. On 10/20/15 at 12:00 PM observation of the two hour barrier above the drop down ceiling over the double doors near the cafeteria revealed a two inch open conduit holding a blue wire, a half inch open conduit holding two lines, and a three inch open conduit holding multiple lines.

On 10/20/15 at 12:00 PM in an interview, Staff Q confirmed the finding.

7. On 10/20/15 at 2:53 PM observation of the one hour barrier around the gift shop storage area revealed the east wall barrier, as observed above the drop down ceiling, had a one inch opening holding blue wire.

On 10/20/15 at 2:53 PM in an interview, Staff Q confirmed the finding.

On 10/21/15 at 9:15 AM a tour was taken of the facility with Staff Q.

8. On 10/21/15 at 11:09 AM observation above the drop down ceiling of the east wall, two hour barrier in trauma room two revealed an open polyvinyl tube and an open quarter inch copper line.

On 10/21/15 at 11:09 AM in an interview, Staff Q confirmed the finding.

9. On 10/21/15 at 11:13 AM observation above the drop down ceiling of the east wall, two hour barrier in the plaster supply room revealed an annular space around a one inch conduit.

On 10/21/15 at 11:13 AM in an interview, Staff Q confirmed the finding.

10. On 10/21/15 at 11:50 AM review of the life safety code drawings revealed a boiler room with a door and protected by two hour construction. Observation of the boiler room on 10/21/15 at 11:50 AM revealed the rating to the door could not be discerned as it was scratched off the label.

On 10/21/15 at 11:50 AM in an interview, Staff Q confirmed the finding.

11. On 10/21/15 at 11:54 AM observation of the east two hour barrier revealed three plumbing lines with annular spaces.

On 10/21/15 at 11:54 AM in an interview, Staff Q confirmed the finding.

12. On 10/21/15 at 11:55 AM observation of east two hour barrier revealed a yellow coated line with an annular space.

On 10/21/15 at 11:55 AM in an interview, Staff Q confirmed the finding.

13. On 10/21/15 at 2:02 PM observation above the drop down ceiling of the two hour barrier along the computed tomography room revealed three conduits with a collective annular space, and one conduit open to air.

On 10/21/15 at 2:02 PM in an interview, Staff Q confirmed the finding.

14. On 10/21/15 at 3:22 PM observation above the drop down ceiling of the south wall, one hour rated barrier in the operating room storage area revealed a half inch, white tipped conduit holding a grey wire.

On 10/21/15 at 3:22 PM, in an interview, Staff Q confirmed the finding.

On 10/21/15 at 3:45 PM a tour was taken of the attic space with Staff Q.

15. On 10/21/15 at 4:06 PM observation of the two hour barrier revealed an access door was cut into the barrier. Observation of the door revealed it had self closing hardware that did not close and latch the door.

On 10/21/15 at 4:06 PM in an interview, Staff Q confirmed the finding.

16. On 10/21/15 at 4:10 PM observation of the one hour rated barrier revealed another access door that was warped to such an extent that it did not close and shut when the self closing hardware was tested.

On 10/21/15 at 4:10 PM, in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure doors in rated barriers had self closers that closed the doors and if so equipped, latched the doors. This has the potential to affect all eight patients at the facility.

Findings include:

On 10/19/15 at 3:10 PM a tour was conducted of the facility with Staff Q.

1.On 10/19/15 at 3:52 PM observation of the double doors on the west side of the patient care unit revealed it was in a two hour barrier with self closing and latching hardware that did not self close and latch when tested.

On 10/19/15 at 3:52 PM in an interview, Staff Q confirmed the finding.

2. On 10/19/15 at 4:03 PM observation of the double doors in the two hour barrier near accounts payable and central supply revealed they did not self close and the attached latching hardware did not latch the door.

3. On 10/19/15 at 4:05 PM observation of the double doors in the two hour barrier leading to the south exit and near CT did not close and latch.

On 10/19/15 at 4:05 PM in an interview, Staff Q confirmed the findings.

4. On 10/19/15 at 4:08 PM observation of the double doors in the two hour barrier by the cafeteria revealed they had self closing and latching hardware that did not self close and latch.

On 10/19/15 at 4:08 PM in an interview, Staff Q confirmed the finding.

5. On 10/20/15 at 10:55 AM observation of the door to the radiologist office revealed it was in a one hour barrier without a self closer.

On 10/20/15 at 10:55 AM in an interview, Staff Q confirmed the finding.

6. On 10/20/15 at 11:50 AM observation of the door in the two hour barrier that is the west wall of the radiology file room revealed a door with self closing and latching hardware that did not self close and latch when tested.

On 10/20/15 at 11:50 AM in an interview, Staff Q confirmed the finding.

7. On 10/20/15 at 2:44 PM observation of the double doors protecting the gift shop from the corridor revealed they were on a magnetic release and had latching hardware. They were also observed to have paraphernalia, e.g. a blanket, hanging off them such that the doors would be unable to close completely.

On 10/20/15 at 2:44 PM in an interview, Staff Q declined to test the doors for fear of damaging the merchandise but confirmed the merchandise would stop the doors from closing completely.

On 10/21/15 at 9:15 AM a tour was taken of the facility with Staff Q.

8. On 10/21/15 at 3:10 PM review of the drawing revealed the door to the storage room, in the one hour barrier and across from patient room three, was in a one hour barrier. On 10/21/15 at 3:10 PM observation of the door revealed it was not on a self closer.

On 10/21/15 at 3:10 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure doors to hazardous areas had self closers. This has the potential to affect all eight patients at the facility.

Findings include:

On 10/20/15 at 9:50 AM a tour of the facility was taken with Staff Q.

On 10/20/15 at 11:50 AM observation of the radiology file room revealed it to contain storage of combustibles in a quantity greater than that typically found in the facility: namely rows of radiology files on shelves. Observation of the entry from the corridor to the room revealed a door without a self closer.

On 10/20/15 at 11:50 AM in an interview, Staff Q confirmed the finding.

Based on record review and staff interview, the facility failed to ensure battery operated lighting was tested monthly and annually, which had the potential to affect any patient at the facility with a census of eight.


Findings include:


Observations were made on tour of the facility on 10/20/15 and 10/21/15 of battery operated emergency lighting units present throughout the facility for emergency illumination. Review of emergency systems records revealed there was no documented testing of battery operated light units. Interview with Staff Q on 10/22/15 at 11:44 AM confirmed there was no documentation of monthly or annual testing for the battery operated lighting units.

Based on record review and staff interview the facility failed to ensure fire drills were conducted at variable times, which had the potential to affect any patient at the facility with a census of eight.


Findings include:


Review of fire drill documentation revealed there were second shift drills conducted in the three o'clock hour, and review of third shift drills revealed all were conducted in the six o'clock hour, thus a pattern of expected times was present. An interview with Staff Q on 10/22/15 at 2:11 PM confirmed the drills were conducted in the same time frames.

Based on observation and interview, the facility failed to maintain its sprinkler system in accordance with National Fire Protection Association 25, 2-4. This has the potential to affect all patients at the facility. The facility census was eight patients.

Findings include:

On 10/21/15 at 9:15 AM a tour was taken of the facility with Staff Q.

On 10/21/15 at 2:46 PM a tour was conducted of the sprinkler room. Although dry barrel sprinkler heads were observed throughout the building, none were observed in the spare sprinkler head cabinet.

On 10/21/15 at 2:46 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each fire extinguisher was readily acceptable in accordance with National Fire Protection Association 10, 1999 edition. This has the potential to affect all patients at the facility. The facility census was eight patients.

Findings include:

On 10/20/15 at 9:50 AM a tour of the facility was taken with Staff Q. On 10/20/15 at 2:37 PM observation of a fire extinguisher in the kitchen revealed it was blocked by a large circular fan in operation.

On 10/20/15 at 2:37 PM in an interview, Staff Q confirmed the finding.

Based on interview and record review, the facility failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4. This has the potential to affect all patients at the facility. The facility had a census of eight patients.

Findings include:

On 10/20/15 at 9:50 AM a tour was taken of the facility with Staff Q. On 10/20/15 at 3:45 PM observation of the one fire barrier in the public relations room revealed it contained a fusible link, curtain damper.

On 10/21/15 at 9:15 AM a tour was taken of the facility with Staff Q. At 1:51 PM observation above the drop down ceiling of the two hour fire barrier in the corridor across from the entrance to the purchase/storage room revealed fusible link, curtain dampers in the barrier.

On 10/22/15 a review of the facility ' s fire safety documentation was completed. It did not reveal when the dampers had last been tested.

On 10/22/15 at 8:20 AM in an interview, Staff Q stated he/she did not know when the dampers had last been tested.

Based on observation and interview, the facility failed to have corridors on the paths of egress free of obstructions. This has the potential to affect all patients at the facility. The facility census was eight patients.

Findings include:

On 10/20/15 at 9:50 AM a tour of the facility was taken with Staff Q. On 10/20/15 at 10:32 AM observation of the double doors leading out of the surgery corridor revealed they were in a path of egress marked by an exit sign. Observation revealed half the doors were blocked by a supply cart stored there.

On 10/20/15 at 10:32 AM in an interview, Staff Q confirmed the finding.

On 10/21/15 at 9:15 AM a tour was taken of the facility with Staff Q.

On 10/21/15 at 3:15 PM observation of the double doors leading out of the surgery corridor revealed they were in a path of egress marked by an exit sign. Observation revealed half the doors were again blocked by a supply cart stored there.

On 10/27/15 at 3:15 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to maintain a two hour fire protective construction between itself and a nonconforming building (a medical office building). This has the potential to affect all patients at the facility. The facility census was eight patients.

Findings include:

On 10/21/15 at 9:15 AM a tour was taken of the facility with Staff Q.

1.On 10/21/15 at 9:15 AM observation of the double doors in the two hour barrier in the corridor that leads to the medical office building revealed the doors had a coordinator and latching hardware that did not coordinate and latch the double doors.

On 10/21/15 at 9:15 AM in an interview, Staff Q confirmed the finding.

2. On 10/21/15 at 9:20 AM observation above the drop down ceiling of the two hour barrier between the facility and the medical office building, as seen from the hospital side, revealed a six inch water line, a turquoise snorkel tube, and a salmon colored line each with annular spaces.

On 10/21/15 at 9:20 AM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure corridor doors with self closing and latching hardware closed and latched the doors. This has the potential to affect all eight patients at the facility.

Findings include:

On 10/19/15 at 3:10 PM a tour was conducted of the facility with Staff Q.

1.On 10/19/15 at 3:10 PM observation of the double doors between the education room and the corridor revealed it had self closing and latching hardware that when tested did not close and latch the doors.

On 10/19/15 at 3:10 PM in an interview, Staff Q confirmed the finding.

2. On 10/19/15 at 3:48 PM observation of the door between the corridor and the men ' s bathroom by the education room revealed it had self closing and latching hardware that did not self close and latch the door.

On 10/19/15 at 3:48 PM in an interview, Staff Q confirmed the finding.

3. On 10/19/15 at 3:55 PM observation of corridor room on room 131 revealed a chair in the room stopped the door from being closed.

On 10/19/15 at 3:55 PM in an interview, Staff Q confirmed the finding.

On 10/21/15 at 9:15 AM a tour was taken of the facility with Staff Q.

4. On 10/21/15 at 3:30 PM observation of the corridor door to the janitor closet revealed it had self closing and latching hardware that did not close and latch the door.

On 10/21/15 at 3:30 PM in an interview, Staff Q confirmed the finding.

Based on observation, interview, and review of the life safety code drawings revealed the facility failed to maintain the rating on its barriers. This has the potential to affect all eight patients at the facility.

Findings include:

On 10/20/15 at 9:50 AM a tour of the facility was taken with Staff Q.

1.On 10/20/15 at 10:30 AM observation of the one hour barrier over the double doors leading to the operating room corridor revealed an open one inch conduit holding three white and one red wire.

On 10/20/15 at 10:30 AM in an interview, Staff Q confirmed the finding.

2. On 10/20/15 at 10:32 AM observation of the same double doors in the one hour barrier revealed a quarter inch gap through the astragal and around the latching hardware. In addition, the doors were not on a coordinator so that when tested, if the door with the astragal closed first, the doors the latching hardware could not work and the doors would not close.

On 10/20/15 at 10:32 AM in an interview, Staff Q confirmed the finding.

3. On 10/20/15 at 10:45 AM observation above the drop down ceiling of the one hour barrier over the double doors leading to the surgery (on left) and radiology (on right) corridor revealed a two inch open conduit holding yellow wires and a three inch open conduit holding yellow lines.

On 10/20/15 at 10:45 AM in an interview, Staff Q confirmed the finding.

4. On 10/20/15 at 11:07 AM observation of the south one hour barrier in the radiologist office revealed a one inch penetration holding a grey wire.

On 10/20/15 at 11:07 AM in an interview, Staff Q confirmed the finding.

5. On 10/20/15 at 11:10 AM observation of the other side of the wall in the communication room revealed a one inch wide by six inch long square cut from the communication room-side dry wall.

On 10/20/15 at 11:10 AM in an interview, Staff Q confirmed the finding.

6. On 10/20/15 at 12:00 PM observation of the two hour barrier above the drop down ceiling over the double doors near the cafeteria revealed a two inch open conduit holding a blue wire, a half inch open conduit holding two lines, and a three inch open conduit holding multiple lines.

On 10/20/15 at 12:00 PM in an interview, Staff Q confirmed the finding.

7. On 10/20/15 at 2:53 PM observation of the one hour barrier around the gift shop storage area revealed the east wall barrier, as observed above the drop down ceiling, had a one inch opening holding blue wire.

On 10/20/15 at 2:53 PM in an interview, Staff Q confirmed the finding.

On 10/21/15 at 9:15 AM a tour was taken of the facility with Staff Q.

8. On 10/21/15 at 11:09 AM observation above the drop down ceiling of the east wall, two hour barrier in trauma room two revealed an open polyvinyl tube and an open quarter inch copper line.

On 10/21/15 at 11:09 AM in an interview, Staff Q confirmed the finding.

9. On 10/21/15 at 11:13 AM observation above the drop down ceiling of the east wall, two hour barrier in the plaster supply room revealed an annular space around a one inch conduit.

On 10/21/15 at 11:13 AM in an interview, Staff Q confirmed the finding.

10. On 10/21/15 at 11:50 AM review of the life safety code drawings revealed a boiler room with a door and protected by two hour construction. Observation of the boiler room on 10/21/15 at 11:50 AM revealed the rating to the door could not be discerned as it was scratched off the label.

On 10/21/15 at 11:50 AM in an interview, Staff Q confirmed the finding.

11. On 10/21/15 at 11:54 AM observation of the east two hour barrier revealed three plumbing lines with annular spaces.

On 10/21/15 at 11:54 AM in an interview, Staff Q confirmed the finding.

12. On 10/21/15 at 11:55 AM observation of east two hour barrier revealed a yellow coated line with an annular space.

On 10/21/15 at 11:55 AM in an interview, Staff Q confirmed the finding.

13. On 10/21/15 at 2:02 PM observation above the drop down ceiling of the two hour barrier along the computed tomography room revealed three conduits with a collective annular space, and one conduit open to air.

On 10/21/15 at 2:02 PM in an interview, Staff Q confirmed the finding.

14. On 10/21/15 at 3:22 PM observation above the drop down ceiling of the south wall, one hour rated barrier in the operating room storage area revealed a half inch, white tipped conduit holding a grey wire.

On 10/21/15 at 3:22 PM, in an interview, Staff Q confirmed the finding.

On 10/21/15 at 3:45 PM a tour was taken of the attic space with Staff Q.

15. On 10/21/15 at 4:06 PM observation of the two hour barrier revealed an access door was cut into the barrier. Observation of the door revealed it had self closing hardware that did not close and latch the door.

On 10/21/15 at 4:06 PM in an interview, Staff Q confirmed the finding.

16. On 10/21/15 at 4:10 PM observation of the one hour rated barrier revealed another access door that was warped to such an extent that it did not close and shut when the self closing hardware was tested.

On 10/21/15 at 4:10 PM, in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure doors in rated barriers had self closers that closed the doors and if so equipped, latched the doors. This has the potential to affect all eight patients at the facility.

Findings include:

On 10/19/15 at 3:10 PM a tour was conducted of the facility with Staff Q.

1.On 10/19/15 at 3:52 PM observation of the double doors on the west side of the patient care unit revealed it was in a two hour barrier with self closing and latching hardware that did not self close and latch when tested.

On 10/19/15 at 3:52 PM in an interview, Staff Q confirmed the finding.

2. On 10/19/15 at 4:03 PM observation of the double doors in the two hour barrier near accounts payable and central supply revealed they did not self close and the attached latching hardware did not latch the door.

3. On 10/19/15 at 4:05 PM observation of the double doors in the two hour barrier leading to the south exit and near CT did not close and latch.

On 10/19/15 at 4:05 PM in an interview, Staff Q confirmed the findings.

4. On 10/19/15 at 4:08 PM observation of the double doors in the two hour barrier by the cafeteria revealed they had self closing and latching hardware that did not self close and latch.

On 10/19/15 at 4:08 PM in an interview, Staff Q confirmed the finding.

5. On 10/20/15 at 10:55 AM observation of the door to the radiologist office revealed it was in a one hour barrier without a self closer.

On 10/20/15 at 10:55 AM in an interview, Staff Q confirmed the finding.

6. On 10/20/15 at 11:50 AM observation of the door in the two hour barrier that is the west wall of the radiology file room revealed a door with self closing and latching hardware that did not self close and latch when tested.

On 10/20/15 at 11:50 AM in an interview, Staff Q confirmed the finding.

7. On 10/20/15 at 2:44 PM observation of the double doors protecting the gift shop from the corridor revealed they were on a magnetic release and had latching hardware. They were also observed to have paraphernalia, e.g. a blanket, hanging off them such that the doors would be unable to close completely.

On 10/20/15 at 2:44 PM in an interview, Staff Q declined to test the doors for fear of damaging the merchandise but confirmed the merchandise would stop the doors from closing completely.

On 10/21/15 at 9:15 AM a tour was taken of the facility with Staff Q.

8. On 10/21/15 at 3:10 PM review of the drawing revealed the door to the storage room, in the one hour barrier and across from patient room three, was in a one hour barrier. On 10/21/15 at 3:10 PM observation of the door revealed it was not on a self closer.

On 10/21/15 at 3:10 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure doors to hazardous areas had self closers. This has the potential to affect all eight patients at the facility.

Findings include:

On 10/20/15 at 9:50 AM a tour of the facility was taken with Staff Q.

On 10/20/15 at 11:50 AM observation of the radiology file room revealed it to contain storage of combustibles in a quantity greater than that typically found in the facility: namely rows of radiology files on shelves. Observation of the entry from the corridor to the room revealed a door without a self closer.

On 10/20/15 at 11:50 AM in an interview, Staff Q confirmed the finding.

Based on record review and staff interview, the facility failed to ensure battery operated lighting was tested monthly and annually, which had the potential to affect any patient at the facility with a census of eight.


Findings include:


Observations were made on tour of the facility on 10/20/15 and 10/21/15 of battery operated emergency lighting units present throughout the facility for emergency illumination. Review of emergency systems records revealed there was no documented testing of battery operated light units. Interview with Staff Q on 10/22/15 at 11:44 AM confirmed there was no documentation of monthly or annual testing for the battery operated lighting units.

Based on record review and staff interview the facility failed to ensure fire drills were conducted at variable times, which had the potential to affect any patient at the facility with a census of eight.


Findings include:


Review of fire drill documentation revealed there were second shift drills conducted in the three o'clock hour, and review of third shift drills revealed all were conducted in the six o'clock hour, thus a pattern of expected times was present. An interview with Staff Q on 10/22/15 at 2:11 PM confirmed the drills were conducted in the same time frames.

Based on observation and interview, the facility failed to maintain its sprinkler system in accordance with National Fire Protection Association 25, 2-4. This has the potential to affect all patients at the facility. The facility census was eight patients.

Findings include:

On 10/21/15 at 9:15 AM a tour was taken of the facility with Staff Q.

On 10/21/15 at 2:46 PM a tour was conducted of the sprinkler room. Although dry barrel sprinkler heads were observed throughout the building, none were observed in the spare sprinkler head cabinet.

On 10/21/15 at 2:46 PM in an interview, Staff Q confirmed the finding.

Based on observation and interview, the facility failed to ensure each fire extinguisher was readily acceptable in accordance with National Fire Protection Association 10, 1999 edition. This has the potential to affect all patients at the facility. The facility census was eight patients.

Findings include:

On 10/20/15 at 9:50 AM a tour of the facility was taken with Staff Q. On 10/20/15 at 2:37 PM observation of a fire extinguisher in the kitchen revealed it was blocked by a large circular fan in operation.

On 10/20/15 at 2:37 PM in an interview, Staff Q confirmed the finding.

Based on interview and record review, the facility failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4. This has the potential to affect all patients at the facility. The facility had a census of eight patients.

Findings include:

On 10/20/15 at 9:50 AM a tour was taken of the facility with Staff Q. On 10/20/15 at 3:45 PM observation of the one fire barrier in the public relations room revealed it contained a fusible link, curtain damper.

On 10/21/15 at 9:15 AM a tour was taken of the facility with Staff Q. At 1:51 PM observation above the drop down ceiling of the two hour fire barrier in the corridor across from the entrance to the purchase/storage room revealed fusible link, curtain dampers in the barrier.

On 10/22/15 a review of the facility ' s fire safety documentation was completed. It did not reveal when the dampers had last been tested.

On 10/22/15 at 8:20 AM in an interview, Staff Q stated he/she did not know when the dampers had last been tested.

Based on observation and interview, the facility failed to have corridors on the paths of egress free of obstructions. This has the potential to affect all patients at the facility. The facility census was eight patients.

Findings include:

On 10/20/15 at 9:50 AM a tour of the facility was taken with Staff Q. On 10/20/15 at 10:32 AM observation of the double doors leading out of the surgery corridor revealed they were in a path of egress marked by an exit sign. Observation revealed half the doors were blocked by a supply cart stored there.

On 10/20/15 at 10:32 AM in an interview, Staff Q confirmed the finding.

On 10/21/15 at 9:15 AM a tour was taken of the facility with Staff Q.

On 10/21/15 at 3:15 PM observation of the double doors leading out of the surgery corridor revealed they were in a path of egress marked by an exit sign. Observation revealed half the doors were again blocked by a supply cart stored there.

On 10/27/15 at 3:15 PM in an interview, Staff Q confirmed the observation.