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Based on observation during tour and staff verification it was determined this facility failed to ensure the patient room corridor doors closed and positive latched shut and was able to resist the passage of smoke. This had the potential to affect all those utilizing these areas of the facility. The patient census was 81 at the beginning of the survey.

Findings include:

Facility tour took place on 05/15/12 to 05/16/12 with staff members A and B. During tour of the second floor west wing observation was made of two patient rooms equipped with double leafed doors which when closed had a gap of approximately one half inch between the doors. The patient room doors affected were numbers 226 and 230.

During tour of the second floor transitional care unit observation was made of two patient rooms equipped with sliding glass doors which when closed failed to positive latch.

During tour of the third floor west wing observation was made of two patient rooms equipped with double leafed doors which when closed had a gap of approximately one half inch between the doors. The patient room doors affected were numbers 332 and 344.

These findings were verified by both staff members during tour.

Based on observation during tour and staff verification it was determined this facility failed to ensure the laundry chute and room enclosure was protected according to the National Fire Protection Association (NFPA) 101, Chapter 9.5. This had the potential to affect all those utilizing this facility. The patient census was 15 the day of the survey.

Findings include:

Facility tour took place with staff members A, C, D and E on 05/16/12. During tour of the laundry chute room observation was made of the chute access door lacking a key lock. This enabled anyone to access the laundry chute. Additionally, the wooden door leading to the chute room was not fire rated and lacked a self closing device. This door was also not equipped with a lock and therefore proposed a potential hazard to occupants of this facility.

This finding was verified by all staff during tour on 05/16/12.

Based on observation during tour and staff verification it was determined this facility failed to ensure access to exits were marked appropriately with visible signs in order to direct occupants to exits. This had the potential to affect all those utilizing these areas of the facility. The patient census was 81 at the beginning of the survey.

Findings include:

Facility tour took place with staff members A and B on 05/15/12 to 05/16/12. During tour of the third floor north wing observation was made two stairwell exits. One was located in the middle of the corridor (stair H) and the other at the far north end. On the west side corridor of the north wing exit signs were located at each exit but the exit sign located near stair H lacked a directional arrow pointing occupants to stair H located in the middle of the north wing.

During tour of the fourth floor north wing observation was made two stairwell exits. One was located in the middle of the corridor (stair H) and the other at the far north end. On the east side corridor of the north wing exit signs were located at each exit but the exit sign located near stair H had a directional arrow pointing occupants opposite the exit access.

These findings were verified by staff members A and B during tour.

Based on staff interview it was determined this facility failed to ensure the smoke detectors were sensitivity tested according to the National Fire Protection Association (NFPA) 72, Chapter 7-3.2.1. This had the potential to affect all those utilizing this facility. The facility census at the start of the survey was 81.

Findings include:

Facility documentation review began on 05/15/12. At this time the documentation for the smoke detector sensitivity tests were requested from staff A. Staff A was not able to provide them and requested from the outside professional company who handles the testing of the smoke detectors to fax over the copy of the latest sensitivity reports. Later in the day on 05/15/12 staff A stated they were still waiting on the reports. On 05/17/12, the last day of the survey, no reports of smoke detector sensitivity testing had been provided.

Based on facility tour and staff verification it was determined this facility failed to ensure the automatic sprinkler system was continually maintained in reliable operating condition in regards to removing the dust and debris from the sprinkler pendant and ensuring all escutcheon rings were in place. This had the potential to affect all those utilizing this facility. The main building census at the beginning of the survey was 81.

Findings include:

Facility tour took place on 05/15/12 to 05/16/12 with staff members A and B. During tour observation was made of several sprinkler heads which were either coated with dust, debris or had missing escutcheon rings in the following locations:

Basement:
*At the southeast stair area observation was made of three dirty sprinkler heads which were also missing their escutcheon rings.

First floor:
*Within the corridor bordering the west side of the kitchen and near the elevators, observation was made of two sprinkler heads which were coated with dust and/or debris.
*Within the kitchen near the food prep line.

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

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 main building census was 81 at the beginning of the survey.

Findings include:

Facility tour took place on 05/15/12 to 05/16/12 with staff members A and B. During tour observation was made of smoke detectors which were mounted near air flow devices in the following locations:

First floor:
*Within the "old admitting area".
*Within the kitchen near the food prep line.

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