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Based on obseravtions and staff interview the facility failed to ensure smoke barriers were maintained. This has the potential to affect all patients, staff, and visitors. The facility had a capacity of 29 and a census of 11.

Findings include:

Observations were made on tour of the second floor 02/11/14 at 2:20 PM above the ceiling in a one hour rated smoke barrier wall above double doors by A 253 Data Room and two bathrooms of two four inch conduits with wire passing through that did not have fire stop material sealing the opening.

Observations were made on the first floor 02/11/14 at 3:33 PM of a set of double doors that were part of a one hour smoke barrier, located past the employee dining area, toward the pain management area, in which one of the doors did not close completely when released from magnetic hold devices.

Based on observations and staff interview the facility failed to ensure penetrations were sealed to maintain a one hour rated fire partition. This has the potential to affect all patients, staff, and visitors. The facility had a capacity of 29 and a census of 11.

Findings include:

Observations were made on 02/11/14 at 3:05 PM above the ceiling of a one hour rated fire partition of a clean holding/ storage room of an air duct work that was open, not connected, passing through the wall. Staff A confirmed the open duct work and said it may be part of an air return system.

Based on observations and staff interview the facility failed ensure exit signage clearly indicated the path of egress. This has the potential to affect all patients, staff, and visitors. The facility had a capacity of 29 and a census of 11.


Findings include:

An observation was made on 02/12/14 at 10:18 AM of an exit sign on the ground level in a corridor near a mechanical room that did not have a directional chevron to coincide with the turn that was indicated on a posted fire evacuation plan in that corridor. Staff A confirmed the lack of directional indication on the exit sign.




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On 02/11/14 at 1:53 P.M. a tour was conducted of the second floor with Staff A. At 2:33 P.M., observing east along the south corridor, a pair of double doors was observed. The double doors would close upon activation of the fire alarm. With the double doors in the closed position, an exit sign on the path of egress could not be observed looking east along the south corridor. On 02/11/14 at 2:33 P.M., in an interview Staff A confirmed the observation.

Based on observations and staff interview the facility failed to ensure smoke detectors were located an appropriate distance from air vents. This has the potential to affect all patients, staff, and visitors. The facility had a capacity of 29 and a census of 11.

Findings include:

An observation was made on 02/12/14 on tour at 3:18 PM of a smoke detector on the ceiling in the hall near the post operative area door that was less than three feet from an air vent. Another smoke detector was observed at 3:22 PM on the ceiling in the waiting room area less than three feet from an air vent. A third smoke detector was observed near bed/ curtain #21 in the Phase 2 area on the ceiling less than three feet from an air vent. A fourth smoke detector was observed at 3:39 PM on the ceiling in the operating room area, in the front hall near an emergency exit less than three feet from an air vent. These observations were confirmed during the tour with staff A.

Based on observation and interview, the facility failed to maintain an automatic sprinkler system with clean sprinkler heads in accordance with NFPA 25. This has the potential to affect all patients, staff, and visitors. The facility had a capacity of 29 and a census of 11.

Findings include:

On 02/11/14 at 1:53 P.M. a tour was conducted of the second floor with Staff A. At 1:53 A.M. in the nourishment room a sprinkler head was observed to be covered in dust such that the fluid in the bulb was difficult to visualize. On 02/11/14 at 1:53 P.M. in an interview Staff A confirmed the observation.

At 2:21 P.M. in room A252 a dirty sprinkler head was observed to be covered in dust such that the fluid in the bulb was difficult to visualize. On 02/11/14 at 3:05 P.M. a tour was conducted of the first floor with Staff A. At 4:12 P.M. in the post anesthesia care unit area over curtain areas B, A, H, and I the sprinkler heads were observed to be covered in dust such that the fluid in the bulb was difficult to visualize. On 02/11/14 at 4:12 P.M. in an interview Staff A confirmed the observation.

At 4:30 P.M. a sprinkler head was observed to be missing an escutcheon in the corridor near operating room #6. On 02/11/14 at 4:30 P.M. in an interview Staff A confirmed the observation.

At 4:48 P.M. near sterilizer #2 a sprinkler head with dirty and rusty struts was observed. On 02/11/14 at 4:48 P.M. in an interview Staff A confirmed the observation.

At 4:50 P.M. a dirty sprinkler head in the soiled work room, room number E149, was observed to be covered in dust such that the fluid in the bulb was difficult to visualize. On 02/11/14 at 4:50 P.M. in an interview Staff A confirmed the observation.

On 02/12/14 at 9:12 A.M. a tour of the first floor resumed with Staff A. At 9:12 A.M. in the waiting area by the bathroom a dirty sprinkler head was observed to be covered in dust such that the fluid in the bulb was difficult to visualize. On 02/12/14 at 9:12 A.M. in an interview Staff A confirmed the observation.

At 9:32 A.M. one dirty sprinkler head was observed in the men's locker room, and two were observed in the women ' s locker room, where the two corridors met. On 02/12/14 at 9:32 A.M. in an interview, Staff A confirmed the observation.

On 02/12/14 at 10:01 A.M. a tour of the basement was conducted with Staff A and B. At 10:01 A.M. in the mechanical room designated A010.0, three sprinkler heads were observed to have their bulbs coated with fire resistive foam that was used on the steel. On 02/12/14 at 10:01 A.M. in an interview Staff A confirmed the observation.

On 02/12/14 at 10:01 A.M. a tour of the laboratory revealed three sprinkler heads observed to be covered in dust such that the fluid in the bulb was difficult to visualize. On 02/12/14 at 10:01 A.M. Staff A confirmed the finding.

Based on observation and interview, the facility failed to have portable fire extinguishers installed in accordance with NFPA 10. This has the potential to affect all patients, staff, and visitors. The facility had a capacity of 29 and a census of 11.


Findings include:

On 02/12/14 at 2:32 P.M. a tour was conducted of the facility with Staff A and B. Observations of operating rooms one and three revealed the fire extinguishers in each had equipment placed in front. On 02/12/14 at 2:32 in an interview, Staff A confirmed the observation.

Based on interview and observation, the facility failed to ensure its medical gas system complied with NFPA 99. This has the potential to affect all patients, staff, and visitors. The facility had a capacity of 29 and a census of 11.


Findings include:

On 02/12/14 at 2:32 P.M. a tour was conducted of the facility with Staff A and B. Observation of the medical gas room revealed the gauges for the nitrogen gas to each read 0.

On 02/12/14 at 3:00 P.M., in an interview, Staff H, the nurse manager, stated there was a delivery made of medical gases earlier in the week, but didn't know what kind or how much. He/she said a staff member had checked the gas levels in the morning, and found the dial to just one bank to read 0 and stated the staff member did not report this to anyone.

On 02/12/14 at 3:00 P.M. in an interview Staff B said he/she did not have any idea there wasn't any nitrogen gas left. Staff B said if he/she had known one bank was empty, then tanks would have been replaced.

On 02/12/14 at 3:00 P.M. observation of the medical gas panel revealed a light indicated the 2nd nitrogen gas bank was in use, but there was still enough gas in the lines to not trigger a loss of gas pressure alarm.

Based on interview and record review, the facility failed to ensure anesthetizing locations were protected in accordance with NFPA 99. This has the potential to affect all patients, staff, and visitors. The patient census was 11.


Findings include:

On 02/14/14 at 10:00 A.M. review of the humidity levels for the operating rooms did not reveal any readings for operating rooms one and two. On 02/14/14 at 10:00 A.M. in an interview Staff A stated he/she didn't have any readings for operating rooms one and two.