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Based on facility observation, review of facility schematics and staff interview and verification, the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas were substantial doors, such as those constructed of 1? inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors were provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. The facility had a census of 18 patients at the time of the survey completed on 01/06/12.

Findings included:

Tour of the facility was completed on 01/05/12 between the hours of 10:25 A.M. and 3:00 P.M. with Staff G and H. The following observations and findings were noted;

1. Review of the facility schematic revealed that a one hour fire rated separation wall was located at the entrance of the emergency department (ED). Doors to the ED were present in the fire rated barrier wall. Observation of the doors revealed there was no fire resistance rating on the doors and no mechanism in place which would allow the doors to remain securely latched when in the closed position.

2. Observation of the door to the blood draw room located in the laboratory area on the first floor, revealed the presence of a Dutch door. The door, located on the corridor, had no closing devices on the upper or lower portion of the Dutch door.

3. Observation of a Dutch door located on the second floor at the clean side of the central supply for the operating rooms revealed there was no closing device on the upper or lower portions of the Dutch door.

Staff G and H, present on the tour verified the observations and the findings.

Based on facility tour and staff interview and verification, the facility failed to ensure that one hour fire rated construction (with ? hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. The facility had a census of 18 patients at the time of the survey completed on 01/06/12.

Findings included:

Tour of the facility was completed on 01/05/12 between the hours of 10:25 A.M. and 3:00 P.M. with Staff G and H. The following observations and findings were noted.

1. Located on the first floor;

a. Observation of a soiled utility/biohazard room, located on the north wing, revealed the room was not provided with an approved automatic fire extinguishing system. Observation of the room construction above the ceiling tiles, revealed a large open portion of the wall. The open area allowed for observation of the space above the ceiling tilesof the adjacent, nurse manager's, office.

b. Observation of the medical record storage area, located next to the third registration office revealed the medical records storage room was not provided with an approved automatic fire extinguishing system. The storage room contained a significant amount of combustible materials such a paper medical records and cardboard boxes. Observation the room construction, above the ceiling tiles revealed penetrations in the wall which separated the storage area and the office. One penetration was noted to be approximately 10 inches by 5 inches in size. The door to the medical records storage area was a wooden door with no noted fire resistance rating.

2. Located on the second floor;

a. Observation of the pulmonary function treatment ( PFT) room revealed the presence of a significant amount of combustible medical records stored in the room. The medical records were stored standing on end on shelves noted to be approximately 12 feet long and 6 feet high. The PFT room was not provided with an approved automatic fire extinguishing system. The door to the room was noted to be wooden with a large wired window. The door had no fire resistance rating.

Staff G and H present on tour verified the observations and the findings.

Based on facility observation and staff interview and verification, the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities. The facility had a census of 18 patients at the time of the survey completed on 01/06/12.

Findings included:

Tour of the facility was completed on 01/05/12 between the hours of 10:25 A.M. and 3:00 P.M. with Staff G and H. During tour of the operating rooms located on the second floor, a small room was observed which contained five, H sized cylinders of nitrous oxide and nitrogen. Staff G stated an update of medical gas equipment had recently been completed.

Observation of the storage area revealed the room had a penetration approximately 12 inches in size located in the ceiling. A smaller penetration was noted on the right wall of the room approximately eight feet from from the floor.

Staff G, present on the tour verified the observations and the findings.

Based on facility observation, review of facility information and staff interview and verification, the facility failed to ensure that generators were inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. The facility had a census of 18 patients at the time of the survey completed on 01/06/12.

Findings included:

On 01/04/12 review of documentation for weekly, monthly and annual maintenance of the facility diesel generator for emergency power was completed. The information revealed the presence of a diesel generator with 209.4 hours of operation. Staff G verified the generator was newer to the facility and was located outside at the rear of the building. Staff G stated there was an older generator present in the mechanical room of the facility which had not been used regularly in the past five years.

Tour of the facility was completed on 01/05/12 between the hours of 10:25 A.M. and 3:00 P.M. with Staff G and H. Observation of the mechanical rooms revealed the presence of an older diesel generator. The generator had a sign placed on it that no longer in use. Interview of Staff G regarding the generator revealed the generator was not used or maintained. Staff G stated that no weekly, monthly or annual maintenance was completed for the generator. Staff G did state that a supply of fuel was still present and was monitored. In addition, removal from the mechanical room would be difficult.

Based on facility observation, review of facility schematics and staff interview and verification, the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas were substantial doors, such as those constructed of 1? inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors were provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. The facility had a census of 18 patients at the time of the survey completed on 01/06/12.

Findings included:

Tour of the facility was completed on 01/05/12 between the hours of 10:25 A.M. and 3:00 P.M. with Staff G and H. The following observations and findings were noted;

1. Review of the facility schematic revealed that a one hour fire rated separation wall was located at the entrance of the emergency department (ED). Doors to the ED were present in the fire rated barrier wall. Observation of the doors revealed there was no fire resistance rating on the doors and no mechanism in place which would allow the doors to remain securely latched when in the closed position.

2. Observation of the door to the blood draw room located in the laboratory area on the first floor, revealed the presence of a Dutch door. The door, located on the corridor, had no closing devices on the upper or lower portion of the Dutch door.

3. Observation of a Dutch door located on the second floor at the clean side of the central supply for the operating rooms revealed there was no closing device on the upper or lower portions of the Dutch door.

Staff G and H, present on the tour verified the observations and the findings.

Based on facility tour and staff interview and verification, the facility failed to ensure that one hour fire rated construction (with ? hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. The facility had a census of 18 patients at the time of the survey completed on 01/06/12.

Findings included:

Tour of the facility was completed on 01/05/12 between the hours of 10:25 A.M. and 3:00 P.M. with Staff G and H. The following observations and findings were noted.

1. Located on the first floor;

a. Observation of a soiled utility/biohazard room, located on the north wing, revealed the room was not provided with an approved automatic fire extinguishing system. Observation of the room construction above the ceiling tiles, revealed a large open portion of the wall. The open area allowed for observation of the space above the ceiling tilesof the adjacent, nurse manager's, office.

b. Observation of the medical record storage area, located next to the third registration office revealed the medical records storage room was not provided with an approved automatic fire extinguishing system. The storage room contained a significant amount of combustible materials such a paper medical records and cardboard boxes. Observation the room construction, above the ceiling tiles revealed penetrations in the wall which separated the storage area and the office. One penetration was noted to be approximately 10 inches by 5 inches in size. The door to the medical records storage area was a wooden door with no noted fire resistance rating.

2. Located on the second floor;

a. Observation of the pulmonary function treatment ( PFT) room revealed the presence of a significant amount of combustible medical records stored in the room. The medical records were stored standing on end on shelves noted to be approximately 12 feet long and 6 feet high. The PFT room was not provided with an approved automatic fire extinguishing system. The door to the room was noted to be wooden with a large wired window. The door had no fire resistance rating.

Staff G and H present on tour verified the observations and the findings.

Based on facility observation and staff interview and verification, the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities. The facility had a census of 18 patients at the time of the survey completed on 01/06/12.

Findings included:

Tour of the facility was completed on 01/05/12 between the hours of 10:25 A.M. and 3:00 P.M. with Staff G and H. During tour of the operating rooms located on the second floor, a small room was observed which contained five, H sized cylinders of nitrous oxide and nitrogen. Staff G stated an update of medical gas equipment had recently been completed.

Observation of the storage area revealed the room had a penetration approximately 12 inches in size located in the ceiling. A smaller penetration was noted on the right wall of the room approximately eight feet from from the floor.

Staff G, present on the tour verified the observations and the findings.

Based on facility observation, review of facility information and staff interview and verification, the facility failed to ensure that generators were inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. The facility had a census of 18 patients at the time of the survey completed on 01/06/12.

Findings included:

On 01/04/12 review of documentation for weekly, monthly and annual maintenance of the facility diesel generator for emergency power was completed. The information revealed the presence of a diesel generator with 209.4 hours of operation. Staff G verified the generator was newer to the facility and was located outside at the rear of the building. Staff G stated there was an older generator present in the mechanical room of the facility which had not been used regularly in the past five years.

Tour of the facility was completed on 01/05/12 between the hours of 10:25 A.M. and 3:00 P.M. with Staff G and H. Observation of the mechanical rooms revealed the presence of an older diesel generator. The generator had a sign placed on it that no longer in use. Interview of Staff G regarding the generator revealed the generator was not used or maintained. Staff G stated that no weekly, monthly or annual maintenance was completed for the generator. Staff G did state that a supply of fuel was still present and was monitored. In addition, removal from the mechanical room would be difficult.