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Based on observation during tour and staff verification it was determined this facility failed to ensure the vertical opening, specifically the stairway, was constructed with at least a one hour fire resistance rating. This had the potential to affect all those who were utilizing this area of the facility. The patient census was 18 at the beginning of the survey.

Findings include:

Facility tour took place on 04/24/12 to 04/25/12 with staff A and C. During tour of the fifth floor observation was made of stairwell door # 3 failing to positive latch shut. This finding was verified by staff members A and C during tour of the fifth floor.

Based on facility tour and staff verification it was determined this facility failed to ensure the access to exits were marked with readily visible signs in order to provide direction to reach exit accesses which were not readily visible by the occupants. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 18.

Findings include:

Facility tour took place on 04/24/12 to 04/25/12 with staff members A and C. During tour of the fifth floor this surveyor was standing in the west corridor at the smoke barrier doors facing toward stairwell # 1 which was not in view. Observation was made from this point of the corridor of no directional sign pointing occupants to the exit access.

This finding was verified by staff members A and C during tour.

Based on observation and interview, the facility failed to maintain each smoke barrier with 30 minute fire resistive rating on floors one and four. This had the potential to affect all patients in the building. The buidling census was 18 patients.

Findings:


On 04/24/12 at 10:50 A.M. a tour was conducted with Staff #2 of the smoke walls of the fourth floor. On the east side of the building the smoke wall between the bank of elevators and the outside wall was observed to have multiple penetrations. Traveling East from the elevator there was a large, one foot penetration, then after the first 90 degree angle in the wall, the wall had insulation and steel studs, then after the second 90 degree angle there was another, approximately two inch square, penetration.

On 04/24/12 at 11:00 A.M. in an interview, Staff #2 confirmed the penetrations, stating that the smoke wall had been moved from a more South location to nearer the elevator bank.

On 04/25/12 at 4:22 P.M. a tour was conducted with Staff #2 of the smoke/fire wall on the first floor running northwest in the northwest corner of the building, between a housekeeping room and a boiler room. In the corner most proximal to the center of the building, two penetrations were observed: one an annular space surrounding a drainage pipe, another an annular space surrounding a sprinkler pipe.

On 04/25/12 at 4:22 P.M. Staff #2 confirmed the observation of the penetrations.

Based on observation during tour and staff verification it was determined this facility failed to ensure the fire/smoke barrier was constructed with at least a two hour fire resistance rating. This had the potential to affect all those utilizing this floor of the facility. The patient census at the beginning of the survey was 18.

Findings include:

Facility tour took place on 04/24/12 with staff A and C. During tour of the two hour fire rated construction observation was made of one unsealed conduit located above the ceiling tile and above the double doors within the corridor separating the emergency department and the medical imaging department.

This finding was verified by staff C during tour on 04/24/12.

Based on interview and observation, the facility failed to ensure the door openings in the smoke barriers on the first and fourth floors had at least a 20 minute fire protection rating. This has the potential to affect all patients in the facility. The census was 18 patients.

Findings:

On 04/24/12 at 10:50 A.M. a tour was conducted with Staff #2 of the smoke walls of the fourth floor. At 11:00 A.M. the smoke wall running to the outside wall, east of the elevator bank, was observed to have a door that was unrated and did not self close.

On 04/24/12 at 11:00 A.M. in an interview Staff #2 confirmed the observation of the unrated door.

On 04/25/12 at 3:20 P.M. a tour was conducted with Staff #2 of the smoke wall running northeast along the physical/occupational therapy area on the first floor. In the smoke wall where the corridor containing the physical/occupational therapy area, and opposite the urgent care waiting area, there was an unrated door in the smoke wall. Adjacent to that door, a door to an electrical closet and part of the smoke wall was unrated.

On 04/25/12 at 3:20 P.M. in an interview Staff #2 confirmed the observation of the unrated doors.

Based on interview and observation, the facility failed to ensure the door to each hazardous area was self closing. This has the potential to affect all patients. The census was 18 patients.

Findings:

On 04/25/12 at 3:20 P.M. a tour was conducted of the urgent care center. Next to triage room #2, the door to the biohazard room did not have a self-closer.

On 04/25/12 at 3:20 P.M. in an interview, Staff #2 confirmed the door did not have a self-closer.

Based on facility tour and staff verification it was determined this facility failed to ensure the access to exits were operable, specifically regarding the stairwell delayed egress door alarm in accordance with the National Fire Protection Association (NFPA) 101, Chapter 7.2.1.6. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 18.

Findings include:

Facility tour took place on 04/24/12 to 04/25/12 with staff members A and C. During tour of the sixth floor which housed long term patients and also provided therapy services, this surveyor observed three stairwell exit access doors equipped with an audible alarm and a panic bar which disengages the door after a 15 second delay once it has been activated. According to staff A during interview on 04/24/12 these doors were equipped with these devices for the protection of the type of patients served in the long term care department. Each door was tested for proper functioning and observation was made of stair door # 1 failing to emit an audible alarm when the panic bar was depressed. The door disengaged after 15 seconds but without the audible alarm sounding an occupant or patient would be able to access the stairwell without staff notification.

This finding was verified by staff members A and C during tour.

Based on record review and interview, the facility failed to ensure the functional test conducted on every required emergency lighting system was performed for not less than 30 seconds. This has the potential to affect all patients in the facility. The facility census was 18 patients.

Findings

Review of the emergency battery operated light preventative maintenance documentation took place on 04/23/12. This document failed to reveal the testing of the emergency lights was performed for the required 30 second duration. The documentation only stated that the lights lit.

On 02/24/12 at 2:00 P.M. in an interview, Staff #1 stated that although the documentation showed tests on the lights were performed, and validated tests were performed, he could not show proof that the lights stayed lit for 30 seconds.

Based on observation during tour and staff verification it was determined this facility failed to ensure the main incoming water valve was electronically supervised so that at least a local alarm will sound when the valve was closed in accordance with the National Fire Protection Association (NFPA) 101 Chapter 9.7.2.1 and NFPA 72 Chapter 2-9.1. This had the potential to affect all those utilizing this facility. The patient census was 18 at the beginning of the survey.

Findings include:

Outdoor facility tour took place the morning of 04/23/12 with staff member A. During tour of the fenced in chiller area observation was made of the incoming main water riser which was secured with a padlock although it was not electronically supervised. This finding was verified by staff A during tour.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition. This had the potential to affect all those utilizing this area of the building. The patient census was 18 at the beginning of the survey.

Findings include:

Facility tour took place on 04/24/12 through 04/25/12 with staff A and C. During tour of the emergency department and cardiac department areas observation was made of several sprinkler heads coated with dust or debris. Locations of these were as follows:

Emergency Dept.:
* Trauma room # 2, four dirty sprinkler heads.
* Exam room # 8, one dirty sprinkler head.
* Physician's dictation area, one dirty sprinkler head.
* Triage room, one dirty sprinkler head.
* Restroom near the entrance, one dirty sprinkler head.

Cardiac Dept.:
* Within the cardiac work room one dirty sprinkler head.
* Within the physician's lounge adjacent to the cardiac department, one dirty sprinkler head.

These findings were verified by staff A and C during tour.

Based on interview and operating room (OR) relative humidity (RH) record review, the facility failed to ensure the RH levels in each operating room were maintained equal to or greater than 35 percent. This has the potential to affect all patients. The patient census was 18.

Findings:

A review of the facility's surgery rooms' temperature and RH log was completed on 04/26/12. The review revealed for OR #1 on 04/07/12 for all three shifts the RH was measured at less than 35 percent: 33 percent on the first, 31 percent on the second, and 31 percent on the third.

The review revealed for OR #2 on 04/04/12, 04/07/12, and 04/08/12 the RH was measured at less than 35 percent.

On 04/04/12 on the first and second shift the RH was measured at 33 percent.

On 04/07/02 on the first shift RH was measured at 27 percent, and on the second and third shift the RH was measured at 25 percent.

On 04/08/12 on the second and third shift the RH was measured at 30 percent.

The review revealed for OR #4 on 04/07/12 and on 04/08/12 the RH was measured at less than 35 percent.

On 04/07/12 on the first and third shift the RH was measured at 31 percent, and on the second shift at 30 percent.

On 04/08/12 on the second shift the RH was measured at 33 percent and 32 percent on the third shift.

On 04/24/12 in the morning Staff #1 stated that the operating rooms were kept at a RH of 30 percent in accordance with guidelines from a professional body. He confirmed the operating rooms were not kept at 35 percent.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 18 at the beginning of the survey.

Findings include:

On 04/25/12 at 1:46 P.M. a tour was conducted of the facility's second floor. At 2:11 P.M. the exam room on the south side of the floor was toured. The tour revealed a smoke detector less than 36 inches from a ventilation source.

On 04/24/12 at 11:12 A.M. a tour was conducted of the fourth floor. The tour revealed a small housekeeping closet with a smoke detector less than 36 inches from a ventilation source.

This finding was verified by staff member B during tour of the second and fourth floors.


21957


Facility tour took place on 04/24/12 to 04/25/12 with staff A and C. During tour of the fifth floor observation was made of three smoke detectors mounted near air flow devices in the following locations:
* Directly in front of the elevators adjacent to the nurse's station.
* Within the storage room adjacent to stairwell # 1.
* Directly in front of the visitor elevator beside stairwell # 3.

This finding was verified by staff members A and C during tour of the fifth floor.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 18 at the beginning of the survey.

Findings include:

Tour of the facility took place with staff A and C on 04/24/12 to 04/25/12. During tour observation was made of smoke detectors which were located near air flow devices in the following locations:

* Within the wound care department
* Within the vending room of the emergency department

These findings were verified by staff A and C during tour.

Based on documentation review, staff interview and observation it was determined this facility failed to ensure the single station smoke detectors were tested according to the National Fire Protection Association (NFPA), Chapter 72 7-2.2. Additionally, this facility failed to ensure the emergency battery operated lights were tested according to NFPA 101 7.9.3. This had the potential to affect all those utilizing this facility. The patient census was less than ten at the time of the survey.

Findings include:

Smoke detector documentation review took place on 04/23/12 but there was no documentation available to verify testing of the smoke detectors for the rehab center. Interview with staff A on 04/24/12 at 2:20 PM revealed the smoke detectors were not on the facility's preventive maintenance list.

Battery operated emergency light documentation review took place on 04/23/12. Observation was made of no 30 second monthly testing or annual tests of the emergency battery operated lights for the sleep center. Interview with staff A on 04/24/12 verified the emergency lights were not on the facility's preventive maintenance.

Rehab Center facility tour took place on 04/25/12 with staff A. During tour observation was made of one emergency exit egress light not functioning which was located at the front entrance egress discharge.

Based on documentation review, staff interview and observation it was determined this facility failed to ensure the single station smoke detectors were tested according to the National Fire Protection Association (NFPA), Chapter 72 7-2.2. Additionally, this facility failed to ensure the emergency battery operated lights were tested according to NFPA 101 7.9.3. This had the potential to affect all those utilizing this facility. The patient census was zero at the time of the survey.

Findings include:

Sleep Center facility tour took place on 04/25/12 with staff A. During tour observation was made of one emergency exit egress light not functioning which was located between sleep lab room number one and two.

Smoke detector documentation review took place on 04/23/12 but there was no documentation available to verify testing of the smoke detectors for the sleep center. Interview with staff A on 04/24/12 at 2:20 PM revealed the smoke detectors were not on the facility's preventive maintenance list. Additionally, staff A stated the single station smoke detectors had been installed just over one year ago.

Battery operated emergency light documentation review took place on 04/23/12. Observation was made of no 30 second monthly testing or annual tests of the emergency battery operated lights for the sleep center. Interview with staff A on 04/24/12 verified the emergency lights were not on the facility's preventive maintenance.

Based on observation during tour and staff verification it was determined this facility failed to ensure the vertical opening, specifically the stairway, was constructed with at least a one hour fire resistance rating. This had the potential to affect all those who were utilizing this area of the facility. The patient census was 18 at the beginning of the survey.

Findings include:

Facility tour took place on 04/24/12 to 04/25/12 with staff A and C. During tour of the fifth floor observation was made of stairwell door # 3 failing to positive latch shut. This finding was verified by staff members A and C during tour of the fifth floor.

Based on facility tour and staff verification it was determined this facility failed to ensure the access to exits were marked with readily visible signs in order to provide direction to reach exit accesses which were not readily visible by the occupants. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 18.

Findings include:

Facility tour took place on 04/24/12 to 04/25/12 with staff members A and C. During tour of the fifth floor this surveyor was standing in the west corridor at the smoke barrier doors facing toward stairwell # 1 which was not in view. Observation was made from this point of the corridor of no directional sign pointing occupants to the exit access.

This finding was verified by staff members A and C during tour.

Based on observation and interview, the facility failed to maintain each smoke barrier with 30 minute fire resistive rating on floors one and four. This had the potential to affect all patients in the building. The buidling census was 18 patients.

Findings:


On 04/24/12 at 10:50 A.M. a tour was conducted with Staff #2 of the smoke walls of the fourth floor. On the east side of the building the smoke wall between the bank of elevators and the outside wall was observed to have multiple penetrations. Traveling East from the elevator there was a large, one foot penetration, then after the first 90 degree angle in the wall, the wall had insulation and steel studs, then after the second 90 degree angle there was another, approximately two inch square, penetration.

On 04/24/12 at 11:00 A.M. in an interview, Staff #2 confirmed the penetrations, stating that the smoke wall had been moved from a more South location to nearer the elevator bank.

On 04/25/12 at 4:22 P.M. a tour was conducted with Staff #2 of the smoke/fire wall on the first floor running northwest in the northwest corner of the building, between a housekeeping room and a boiler room. In the corner most proximal to the center of the building, two penetrations were observed: one an annular space surrounding a drainage pipe, another an annular space surrounding a sprinkler pipe.

On 04/25/12 at 4:22 P.M. Staff #2 confirmed the observation of the penetrations.

Based on observation during tour and staff verification it was determined this facility failed to ensure the fire/smoke barrier was constructed with at least a two hour fire resistance rating. This had the potential to affect all those utilizing this floor of the facility. The patient census at the beginning of the survey was 18.

Findings include:

Facility tour took place on 04/24/12 with staff A and C. During tour of the two hour fire rated construction observation was made of one unsealed conduit located above the ceiling tile and above the double doors within the corridor separating the emergency department and the medical imaging department.

This finding was verified by staff C during tour on 04/24/12.

Based on interview and observation, the facility failed to ensure the door openings in the smoke barriers on the first and fourth floors had at least a 20 minute fire protection rating. This has the potential to affect all patients in the facility. The census was 18 patients.

Findings:

On 04/24/12 at 10:50 A.M. a tour was conducted with Staff #2 of the smoke walls of the fourth floor. At 11:00 A.M. the smoke wall running to the outside wall, east of the elevator bank, was observed to have a door that was unrated and did not self close.

On 04/24/12 at 11:00 A.M. in an interview Staff #2 confirmed the observation of the unrated door.

On 04/25/12 at 3:20 P.M. a tour was conducted with Staff #2 of the smoke wall running northeast along the physical/occupational therapy area on the first floor. In the smoke wall where the corridor containing the physical/occupational therapy area, and opposite the urgent care waiting area, there was an unrated door in the smoke wall. Adjacent to that door, a door to an electrical closet and part of the smoke wall was unrated.

On 04/25/12 at 3:20 P.M. in an interview Staff #2 confirmed the observation of the unrated doors.

Based on interview and observation, the facility failed to ensure the door to each hazardous area was self closing. This has the potential to affect all patients. The census was 18 patients.

Findings:

On 04/25/12 at 3:20 P.M. a tour was conducted of the urgent care center. Next to triage room #2, the door to the biohazard room did not have a self-closer.

On 04/25/12 at 3:20 P.M. in an interview, Staff #2 confirmed the door did not have a self-closer.

Based on facility tour and staff verification it was determined this facility failed to ensure the access to exits were operable, specifically regarding the stairwell delayed egress door alarm in accordance with the National Fire Protection Association (NFPA) 101, Chapter 7.2.1.6. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 18.

Findings include:

Facility tour took place on 04/24/12 to 04/25/12 with staff members A and C. During tour of the sixth floor which housed long term patients and also provided therapy services, this surveyor observed three stairwell exit access doors equipped with an audible alarm and a panic bar which disengages the door after a 15 second delay once it has been activated. According to staff A during interview on 04/24/12 these doors were equipped with these devices for the protection of the type of patients served in the long term care department. Each door was tested for proper functioning and observation was made of stair door # 1 failing to emit an audible alarm when the panic bar was depressed. The door disengaged after 15 seconds but without the audible alarm sounding an occupant or patient would be able to access the stairwell without staff notification.

This finding was verified by staff members A and C during tour.

Based on record review and interview, the facility failed to ensure the functional test conducted on every required emergency lighting system was performed for not less than 30 seconds. This has the potential to affect all patients in the facility. The facility census was 18 patients.

Findings

Review of the emergency battery operated light preventative maintenance documentation took place on 04/23/12. This document failed to reveal the testing of the emergency lights was performed for the required 30 second duration. The documentation only stated that the lights lit.

On 02/24/12 at 2:00 P.M. in an interview, Staff #1 stated that although the documentation showed tests on the lights were performed, and validated tests were performed, he could not show proof that the lights stayed lit for 30 seconds.

Based on observation during tour and staff verification it was determined this facility failed to ensure the main incoming water valve was electronically supervised so that at least a local alarm will sound when the valve was closed in accordance with the National Fire Protection Association (NFPA) 101 Chapter 9.7.2.1 and NFPA 72 Chapter 2-9.1. This had the potential to affect all those utilizing this facility. The patient census was 18 at the beginning of the survey.

Findings include:

Outdoor facility tour took place the morning of 04/23/12 with staff member A. During tour of the fenced in chiller area observation was made of the incoming main water riser which was secured with a padlock although it was not electronically supervised. This finding was verified by staff A during tour.

Based on observation during facility tour and staff verification it was determined this facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition. This had the potential to affect all those utilizing this area of the building. The patient census was 18 at the beginning of the survey.

Findings include:

Facility tour took place on 04/24/12 through 04/25/12 with staff A and C. During tour of the emergency department and cardiac department areas observation was made of several sprinkler heads coated with dust or debris. Locations of these were as follows:

Emergency Dept.:
* Trauma room # 2, four dirty sprinkler heads.
* Exam room # 8, one dirty sprinkler head.
* Physician's dictation area, one dirty sprinkler head.
* Triage room, one dirty sprinkler head.
* Restroom near the entrance, one dirty sprinkler head.

Cardiac Dept.:
* Within the cardiac work room one dirty sprinkler head.
* Within the physician's lounge adjacent to the cardiac department, one dirty sprinkler head.

These findings were verified by staff A and C during tour.

Based on interview and operating room (OR) relative humidity (RH) record review, the facility failed to ensure the RH levels in each operating room were maintained equal to or greater than 35 percent. This has the potential to affect all patients. The patient census was 18.

Findings:

A review of the facility's surgery rooms' temperature and RH log was completed on 04/26/12. The review revealed for OR #1 on 04/07/12 for all three shifts the RH was measured at less than 35 percent: 33 percent on the first, 31 percent on the second, and 31 percent on the third.

The review revealed for OR #2 on 04/04/12, 04/07/12, and 04/08/12 the RH was measured at less than 35 percent.

On 04/04/12 on the first and second shift the RH was measured at 33 percent.

On 04/07/02 on the first shift RH was measured at 27 percent, and on the second and third shift the RH was measured at 25 percent.

On 04/08/12 on the second and third shift the RH was measured at 30 percent.

The review revealed for OR #4 on 04/07/12 and on 04/08/12 the RH was measured at less than 35 percent.

On 04/07/12 on the first and third shift the RH was measured at 31 percent, and on the second shift at 30 percent.

On 04/08/12 on the second shift the RH was measured at 33 percent and 32 percent on the third shift.

On 04/24/12 in the morning Staff #1 stated that the operating rooms were kept at a RH of 30 percent in accordance with guidelines from a professional body. He confirmed the operating rooms were not kept at 35 percent.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 18 at the beginning of the survey.

Findings include:

On 04/25/12 at 1:46 P.M. a tour was conducted of the facility's second floor. At 2:11 P.M. the exam room on the south side of the floor was toured. The tour revealed a smoke detector less than 36 inches from a ventilation source.

On 04/24/12 at 11:12 A.M. a tour was conducted of the fourth floor. The tour revealed a small housekeeping closet with a smoke detector less than 36 inches from a ventilation source.

This finding was verified by staff member B during tour of the second and fourth floors.


21957


Facility tour took place on 04/24/12 to 04/25/12 with staff A and C. During tour of the fifth floor observation was made of three smoke detectors mounted near air flow devices in the following locations:
* Directly in front of the elevators adjacent to the nurse's station.
* Within the storage room adjacent to stairwell # 1.
* Directly in front of the visitor elevator beside stairwell # 3.

This finding was verified by staff members A and C during tour of the fifth floor.

Based on observation during tour and staff verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. This had the potential to affect all patient's, staff and visitors utilizing the facility. The facility census was 18 at the beginning of the survey.

Findings include:

Tour of the facility took place with staff A and C on 04/24/12 to 04/25/12. During tour observation was made of smoke detectors which were located near air flow devices in the following locations:

* Within the wound care department
* Within the vending room of the emergency department

These findings were verified by staff A and C during tour.

Based on documentation review, staff interview and observation it was determined this facility failed to ensure the single station smoke detectors were tested according to the National Fire Protection Association (NFPA), Chapter 72 7-2.2. Additionally, this facility failed to ensure the emergency battery operated lights were tested according to NFPA 101 7.9.3. This had the potential to affect all those utilizing this facility. The patient census was less than ten at the time of the survey.

Findings include:

Smoke detector documentation review took place on 04/23/12 but there was no documentation available to verify testing of the smoke detectors for the rehab center. Interview with staff A on 04/24/12 at 2:20 PM revealed the smoke detectors were not on the facility's preventive maintenance list.

Battery operated emergency light documentation review took place on 04/23/12. Observation was made of no 30 second monthly testing or annual tests of the emergency battery operated lights for the sleep center. Interview with staff A on 04/24/12 verified the emergency lights were not on the facility's preventive maintenance.

Rehab Center facility tour took place on 04/25/12 with staff A. During tour observation was made of one emergency exit egress light not functioning which was located at the front entrance egress discharge.

Based on documentation review, staff interview and observation it was determined this facility failed to ensure the single station smoke detectors were tested according to the National Fire Protection Association (NFPA), Chapter 72 7-2.2. Additionally, this facility failed to ensure the emergency battery operated lights were tested according to NFPA 101 7.9.3. This had the potential to affect all those utilizing this facility. The patient census was zero at the time of the survey.

Findings include:

Sleep Center facility tour took place on 04/25/12 with staff A. During tour observation was made of one emergency exit egress light not functioning which was located between sleep lab room number one and two.

Smoke detector documentation review took place on 04/23/12 but there was no documentation available to verify testing of the smoke detectors for the sleep center. Interview with staff A on 04/24/12 at 2:20 PM revealed the smoke detectors were not on the facility's preventive maintenance list. Additionally, staff A stated the single station smoke detectors had been installed just over one year ago.

Battery operated emergency light documentation review took place on 04/23/12. Observation was made of no 30 second monthly testing or annual tests of the emergency battery operated lights for the sleep center. Interview with staff A on 04/24/12 verified the emergency lights were not on the facility's preventive maintenance.