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Based on facility observation and staff 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 with no impediments that prevented the closing of the doors. The doors were not provided with a means suitable for keeping the doors closed. Six patient rooms were affected. The facility had capacity for 29 patients with a census of 19 patients at the time of the survey.

Findings included:

On 01/25/11 at 2:00 P.M. tour of the facility was conducted with Staff Q. Observation of doors leading to patient rooms 602, 613, 614, 615, 616 and 6208 were noted to be unable to positively latch when pulled closed.

Room 602 was noted to have a broken latching mechanism. Room 616 and 6208 were not able to be closed due to the placement of a kit placed over the door which contained personal protective requirement (PPE). Metal hooks which held the kits on the doors prevented the doors from being securely closed and able to latch. Room 616 was noted to have a bent door stop at the top of the door and a PPE kit hanging on the door which prevented the door from securely latching.

Staff Q present on the tour verified the doors were unable to securely latch due to disrepair or placement of the PPE kits or both.

Based on facility observation and staff interview and verification, the facility failed to ensure that access to exits were marked by approved, readily visible signs in all cases where the exit or way to reach exit was not readily apparent to the occupants. All patients and visitors could potentially be affected. The facility had capacity for 29 patients with a census of 19 patients at the time of the survey.

Findings included:

On 01/25/11 at 2:00 P.M. tour of the facility was conducted with Staff Q. Observation of the south stairwell from the sixth floor facility to the level of exit discharge, revealed that exit discharge was in a corridor on the first floor. Exit signage indicated that once through the stairwell door on the first floor travel to an exit was continue to the right in a corridor. Near the end of that corridor, there was no visible signage to indicate the way to the exit.

Interview of Staff Q present on the tour verified there was no signage near the end of the corridor to indicate that access to the exit was to the left or right.

Based on observation during tour and staff verification it was determined this facility failed to ensure smoke barriers were constructed with at least a one half hour fire resistance rating. This had the potential to effect all staff, patient's and visitor's utilizing this facility. The total patient census was 13 at the time of the survey.

Findings include:

Tour of the facility took place on 01/25/11 from 1:00 PM to 3:00 PM with staff members X and Y. During tour of the smoke barrier near the nurse's station which separated the medication room form the storage room, observation was made above the ceiling tile of a six to eight inch duct which was not sealed on the top portion. The unsealed area was approximated as one inch wide by eight inches across. This was verified by staff X during tour.

Based on review of facility documentation and staff interview and verification the facility failed to ensure that fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The facility had capacity for 29 patients with a census of 19 patients at the time of the survey.

Findings included:

On 01/25/11 between 11:00 AM. and 12:00 P.M. documentation of completed fire drills for 2010 and to date in 2011 were reviewed with Staff P and Q. It was verified the facility staff work 12 hours shifts, 7:00 A.M. until 7:00 P.M. and 7:00 P.M. until 7:00 A.M.

Review of documented fire drills which included the names of the participants, revealed there was no documented fire drill for the second quarter of 2010 for staff working during the hours of 7:00 A.M. until 7:00 P.M.

Staff P and Q verified there was no documented evidence the facility staff had participated in a fire drill for the second quarter 2010.





21957

Based on observation and staff interview, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the 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 had capacity for 29 patients with a census of 21 patients at the time of the survey.

Findings include:

On 01/27/11 at 8:37 AM the fire alarm was activated in the dietary department which affected this sixth floor health care entity. Interview with staff C at 8:40 AM reveals this was a drill. Tour of the north and south wings during the drill reveals smoke detectors located near air flow devices in the following locations:

North wing corridor near room # 605 and within the nurses station.
South wing corridor near room # 620FO5.

These findings were verified with staff C at 8:50 AM.

Based on observation during tour and staff verification, it was determined this facility failed to ensure the sprinkler system was maintained in reliable operating condition so as to provide adequate suppression in the event of an emergency. This had the potential to affect all staff, patient's and visitor's utilizing this area of the facility. The facility census was 12 at the time of the survey.

Findings include:

Tour of the facility took place on 01/26/11 form 9:15 AM to 10:50 AM with staff U. Observation in patient room number 210 revealed a sprinkler head which had a an approximate one inch by three inch piece of paper attached to the sprinkler base. This paper was covering approximately one half of the sprinkler head. This finding was verified by staff U when staff U utilized a ladder to reach up and remove this obstruction from the sprinkler base.