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Based on observation and staff verification during tour of the smoke barrier it was determined this facility failed to ensure the smoke barrier was constructed with at least a one hour fire rating according to the National Fire Protection Association (NFPA) 101, Chapters 19 and 8.3. This could potentially affect all patients, visitors and staff utilizing this facility. The patient census was 18 on the day of the survey.
Findings include:
Tour of the facility took place on 07/19/11 with staff members Q, R and S. During tour of the one hour fire rated smoke barrier located at the back side of the nurses ' station and from within the clean utility room, observation was made above the ceiling tiles of an approximate 18 foot by two foot section of drywall missing from just above the top of the ceiling tiles to the upper deck.
This finding was observed by staff members R and S during the tour on 07/19/11.

Based on observation during tour of the pharmacy department and staff verification, it was determined this facility failed to ensure the exit access was readily available in regards to the exit access door equipped with two latching mechanisms. This had the potential to affect all personnel utilizing this area. The facility census at the beginning of the survey was 39.

Findings include:

Tour of the pharmacy department took place on 07/20/11 with staff B. Observation was made of the rear exit access door having two separate latching mechanisms. One latching mechanism was a door handle equipped with a push button lock which, when locked, would disengage by pushing down on the door handle.
The second locking mechanism was located a few inches above the door handle and was observed to be a deadbolt equipped with a thumb latch device. This door was not able to be opened with one simple effort from the egress side.
This was verified by staff B when he/she attempted to open the door and using two hands, one to grab the door handle and push down and the other to reach up to the thumb latch and twist to disengage the deadbolt.

Based on review of smoke detector inspection and testing documentation, it was determined this facility failed to ensure all smoke detectors were sensitivity tested according to the National Fire Protection Association (NFPA) 72, Chapter 7-3.2.1. This could potentially affect all patients, visitors and staff utilizing this facility. The patient census was 18 on the day of the survey.
Findings include:
Documentation review of the smoke detector inspection and testing took place on 07/19/11. The annual testing was performed by an outside professional company on 06/08/11. Sensitivity testing of the smoke detectors was not noted on the annual test reports. This was brought to the attention of staff S at 2:45 PM on 07/19/11. Staff S made a phone call to the company who performed the annual test and found that they have never performed sensitivity testing of the smoke detectors. Staff S stated they will have this taken care of.

Based on observation during tour of the pharmacy department and staff verification, it was determined this facility failed to ensure the exit access was readily available in the event of an emergency in regards to keeping the exit access free from obstructions. This had the potential to affect all personnel utilizing this area. The facility census at the beginning of the survey was 39.

Findings include:

Tour of the pharmacy department took place on 07/20/11 with staff B. Observation was made of the rear exit access door from the side of egress side having a med card blocking the door and preventing it from being opened readily in the event of an emergency.
Once the med cart was removed and the door was opened, observation was made on the opposite side of egress, of a small mobile storage unit standing about three feet tall with another type of storage device placed on top. The storage units in total were observed to be blocking the entire width of the exit access and from the floor to about four feet high.

Interview with staff O at approximately 10:20 AM reveals the space occupying the opposite side of the exit access is a home health department.

This was verified by staff B when he/she attempted to open the door and using two hands, one to grab the door handle and push down and the other to reach up to the thumb latch and twist to disengage the deadbolt.