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Based on observations, and staff interviews, the facility failed to ensure corridor doors had gaps less than 1/8 inch. This affected a total of 9 of 9 patient room doors in the High Observation Unit. The code at 18.3.6.3.1 requires corridor doors to resist the passage of smoke. The facility has a census of 39 patients at the time of the survey.

Findings include:

A tour was conducted on 05/28/13 between 2:08 PM and 4:30 PM with Staff A, K, and L and with Staff A and L on 05/29/13 between 10:08 AM and 10:13 AM.

The following High Observation Unit patient corridor doors were observed with double leaf patient room corridor doors that contained greater than a 1/8 inch gap between the door leafs. These were doors to room #101 through #109. The door to patient room #102 failed to latch into the double leaf door strike plate when tested during tour.

These door gaps were verified with Staff A and L during the time of the tour on 05/28/13 and 05/29/13.

Based on observations, staff interviews, and the facility life safety floor plan, it was not readily apparent where the exit was located for two exit access areas of the building. The code at 7.10.1.4 requires access to exits be marked with approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent. The census on the first day of the survey was thirty-nine patients.

Findings include:


A tour was conducted on 05/28/13 between 2:08 PM and 4:30 PM with Staff A, K, and L. The administrative corridor was observed L-shaped. One portion of this corridor was approximately 23 feet long and the other section was approximately 75 feet in length. Multiple unlocked doors, leading into offices, were observed in the 75 feet corridor. The junction of these two corridors lacked an exit directional sign to indicate the exit access door was at the end of the 23 feet corridor.

The pharmacy was observed with a larger room with free standing shelves in the center of the room, and two smaller rooms. The exit access door lacked a directional exit sign indicating the path of exit.

This was verified with Staff A, K, and L at the time of the tour.

Based on observations and staff interviews, the facility failed to ensure three exits were arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness, in accordance with the code at 18.2.8 and 7.8. The facility has a census of 39 patients at the time of the survey.

Findings include:

A tour was conducted on 05/28/13 between 2:08 PM and 4:30 PM with Staff A, K, and L. During this tour, observations revealed three exit discharges without the required lighting at the outside of the exit discharges. These exits were located outside kitchen dining room, at the ambulance exit, and between the exit by radiology and respiratory departments. These exits were observed with light fixtures containing a single bulb.

This was verified with Staff A, K, and L during tour.

Based on observations and staff interviews, the facility failed to ensure sprinkler heads were free from foreign matter such as dirt and dust in accordance with the code at 18.7.6 and NFPA 25 at 2-2.1. This affected three sprinkler heads in the kitchen. The facility has a census of 39 patients at the time of the survey.

Findings include:

A tour was conducted on 05/28/13 between 2:08 PM and 4:30 PM with Staff A, K, and L. During this tour, three sprinkler heads in the kitchen food prep area were observed with a heavy coating of dust and dirt. This was verified with Staff K and L during tour. On 05/29/13 at 9:00 AM, Staff L informed the surveyor the dirty sprinkler heads had been cleaned on 05/29/13.

Based on staff interview and review of the generator logs, the facility failed to provide documented evidence of week inspections of the generator for three weeks between January 2013 and May 2013. This could affect all patients, staff, and visitors. The census on the first survey day was thirty-nine patients.

Findings include:

On 05/29/13 a review of the weekly generator inspection logs revealed the generator was exercised 35 minutes during the weeks of 01/24/13, 02/14/13, and 04/11/13. An interview was conducted with Staff K on 05/29/13 at 2:30 PM. This employee stated the generator are exercised 30 minutes a week with a 5 minute cool down. Staff K verified the lack of documented weekly inspection logs for the aforementioned weeks.

Based on staff interview and review of the fire watch plan for the automatic sprinkler system, the facility failed to ensure this plan contained information on notifying the authority having jurisdiction, responsible person to conduct the fire watch, and frequency of the fire watch. This could affect all patients, staff, and visitors. The census on the first day of survey was thirty-nine patients.

Findings include:

A review was conducted of the fire watch plan for the sprinkler system on 05/29/13 at 3:30 PM. This plan was silent to notification of the authority having jurisdiction, the person responsible to conduct the fire watch, and the frequency of the fire watch. This was verified with Staff K during the aforementioned review of the plan.

Based on staff interview and review of the fire watch plan for the required fire alarm system, the facility failed to ensure this plan contained information on notifying the authority having jurisdiction, the person responsible to conduct the fire watch, and the frequency of the fire watch. This could affect all patients, staff, and visitors. The census on the first day of survey was thirty-nine patients.

Findings include:

A review was conducted of the fire watch plan for the fire alarm system on 05/29/13 at 3:30 PM. This plan was silent to notification of the authority having jurisdiction, the identification of the person responsible to conduct the fire watch, and the frequency of the fire watch. This was verified with Staff K during the aforementioned review of the plan.