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Based on observation during tour of the building and staff verification it was determined this facility failed to ensure all doors protecting corridor openings, specifically patient room doors, were capable of resisting the passage of smoke. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 25.

Findings include:

Tour of the facility took place on 06/28/11 with staff member A. During tour observation was made of three patient room doors that failed to close completely due to an isolation box (small box which contains isolation equipment used for that specific patient within that specific room) mounted from the top of the door by metal hangers. When the patient room door was pulled to a closed position, the doors failed to close completely leaving a small gap. These doors were identified to patient room numbers 5102, 5104 and 5120.

These findings were verified and acknowledged by staff A during tour. Staff A did remove the isolation boxes during tour and adjusted the hangers to enable the identified doors to close properly.

Based on review of sprinkler testing documentation, it was determined this facility failed to ensure the automatinc sprinkler system was inspected quarterly and tested annually. This had the potential to affect all those who utilize this facility. The total patient census at the beginning of the survey was 25.

Findings include:

Documentation review of the sprinkler system inspection and testing took place on 06/28/11 with staff B and 06/29/11 with staff A.
On 06/28/11 at approximately 1:30 PM, a request was made for the quarterly sprinkler test reports. Staff A presented to the surveyors a binder containing computer generated print outs and a few copies of a company letter head containing very limited tests of sprinkler components. In review of these documents, observation was made that they failed to contain any of required items for the quarterly sprinkler inspection. Likewise the annual test report failed to contain the comprehensive testing of all sprinkler system devices. Surveyors requested from Staff A additional documentation and to provide them in the morning.
On 06/29/11 at approximately 8:30 AM a request was made from staff B for the sprinkler testing documentation. At approximately 3:30 PM staff B presented to the surveyors the same computer printed reports that were observed on 06/28/11.
No additional sprinkler reports were presented to the surveyors by the time of the exit conference on 06/30/11.

Based on observation during tour and staff verification it was determined this facility failed to ensure the fire extinguishers were mounted in accordance with the National Fire Protection Association 10, chapter 4-3.2 and 1-6.10. This had the potential to affect all those utilizing this facility. The patient census at the beginning of the survey was 25.

Findings include:

Tour of the facility took place on 06/28/11 with staff A. During tour of the material management room, observation was made of a portable fire extinguisher mounted above the five foot level and was also mounted above a file cabinet which did not allow for easy access during an emergency.
Additionally, observation was made of a portable fire extinguisher located within a wall case near stairwell number six. A portable TV and stand was observed to be located directly in front of the fire extinguisher which did not allow easy access.

Staff A verified these findings 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 facility census was 25 at the beginning of the survey.

Findings include:

Tour of the facility took place with staff A on 06/28/11. During tour observation was made of several smoke detectors which were located near air flow devices in the following areas:
Patient room numbers: 5105, 5107, 5112, 5114 and 5118.
Materials management room and the chief operating officer's room.

These findings were verified by staff A during tour.