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Based on observation and interview with facility staff , the facility failed to ensure 2 of 10 doors to hazardous rooms will resist the passage of smoke. In the event of a fire all clients may be affected.

Findings Include:

On 05-30-2012 at 11:00 a.m. observation revealed the Respiratory Supply room door and the Emergency Room Storage door are not self closing.

At the time of observation staff member M stated the rooms were once used as nonhazardous areas.

Based on observation and interview with facility staff , the facility failed to ensure exit doors can be locked and remain unlocked in an emergency. In the event of a fire all clients may be affected.

Findings Include:

On 05-30-2012 at 1:00 p.m. observation revealed that exit doors with access control locks are not provided with a second means of unlocking them that will keep them unlocked until manually reset.

At the time of observation staff member M stated the facility was unaware of the requirement.

Based on observation and interview with facility staff , the facility failed to ensure all areas of the facility are sprinkler protected. In the event of a fire all clients may be affected.

Findings Include:

On 05-30-2012 at 12:00 p.m. observation revealed the drive through canopy and the covered walk at the front of the facility are combustible construction and are not sprinkler protected.

At the time of observation on 05-30-2012 staff member M stated the facility was aware of the lack of sprinklers and was in the process of getting areas covered.

Based on observation and interview with facility staff , the facility failed to ensure 2 of 10 doors to hazardous rooms will resist the passage of smoke. In the event of a fire all clients may be affected.

Findings Include:

On 05-30-2012 at 11:00 a.m. observation revealed the Respiratory Supply room door and the Emergency Room Storage door are not self closing.

At the time of observation staff member M stated the rooms were once used as nonhazardous areas.

Based on observation and interview with facility staff , the facility failed to ensure exit doors can be locked and remain unlocked in an emergency. In the event of a fire all clients may be affected.

Findings Include:

On 05-30-2012 at 1:00 p.m. observation revealed that exit doors with access control locks are not provided with a second means of unlocking them that will keep them unlocked until manually reset.

At the time of observation staff member M stated the facility was unaware of the requirement.

Based on observation and interview with facility staff , the facility failed to ensure all areas of the facility are sprinkler protected. In the event of a fire all clients may be affected.

Findings Include:

On 05-30-2012 at 12:00 p.m. observation revealed the drive through canopy and the covered walk at the front of the facility are combustible construction and are not sprinkler protected.

At the time of observation on 05-30-2012 staff member M stated the facility was aware of the lack of sprinklers and was in the process of getting areas covered.