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Based on observation and interview, the facility failed to ensure that six of twelve smoke/fire doors added during a 2011 significant expansion and renovation were equipped with Rabbets, bevels or astragals (smoke resistant groove, bevel or strip along the meeting edges of on one or both doors that overlaps and prevents the spread of smoke or fire into unaffected areas) in areas of new construction in accordance with NAPA 2000, chapter 18.3.7.8, New Health Care Occupancies.

The Centers for Medicare and Medicaid Services has determined that after March 13, 2003, any expansion or major modification in an existing facility involving 50 percent or more that 4,500 square feet of the involved smoke compartment must be surveyed under the 2000 New Life Safety Code. (Appendix I)

18.3.7.8 Rabbets, bevels or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of the door frames in smoke barriers. Positive latching hardware shall not be required. Center mullions shall be prohibited. NAPA 2000 (new).

This deficient practice potentially exposes all staff and patients and fails to protect them from the spread of smoke throughout the structure into unaffected areas. The facility census was eight.

Findings included:

1. Observation on 11/10/14 at 3:30 PM through 4:30 PM showed the following:
- No rabbet, astragal, or bevel was on a pair of fire doors (2-32 and 2-33) located in the north corridor of the second floor medical-surgical wing.
- No rabbet, astragal, or bevel was on a pair of unlabeled fire doors located in the south corridor of the second floor medical-surgical wing.
- No rabbet, astragal, or bevel was on a pair of smoke doors in the second floor Obstetrics corridor (located mid-corridor, just west of the elevators).
- No rabbet, astragal, or bevel was on a pair of smoke doors at the west end of the the second floor Obstetrics corridor.
- No rabbet, astragal, or bevel was on a pair of smoke doors of an east-west corridor of first floor, across from room 1-312 in the medical clinic area.
- No rabbet, astragal, or bevel was on a pair of smoke doors of an east-west corridor of first floor, just outside Exam Room #1 of the medical clinic.
2. During an interview on 03/03/14, Staff DJ, Maintenance stated that the facility completed a significant renovation and expansion in 2011, and several smoke and fire doors were established or replaced. He acknowledged the finding and stated that they had tried metal astragals but they bent easily and prevented doors from closing tightly at the meeting edges. He stated that the rubber strips attached with adhesive with moderate success, but the strips tended to peel off. He stated that the vendor had explained that the edges of the composite doors were engineered to expand in a fire and close the gap between the meeting edges, however, the doors would not react and expand to impede smoke without the added temperature of a fire.

Based upon observation, record review and interview, the facility kitchen failed to store flammable liquids in an approved container suitable for storage of flammable and combustible liquids, in accordance with NFPA 30 and NFPA 99. This deficient practice-the storage of flammables in a moderately hazardous area potentially affects the safety of staff and patients. The patient census was eight.

Findings included:

1. Observations on 11/11/14 at 9:00 AM showed a case of flammable liquid product used for chafing, (heating of casseroles on a food service line) that contained one or more flammable alcohol-based chemicals such as glycol, ethanol, methanol or alcohol on a wire shelf in the kitchen's dry storage room. Approximately 20 containers of the product remained in the 24 count box. Other products stored in the room were combustibles; boxes of paper and plastic ware, paper napkins, utensils, and pre-packaged condiments.

2. Review of facility policy titled Maintenance Standards for Combustible Materials dated 08/2014, showed that the maintenance department is assigned responsibility for the safe storage of all flammable liquids and gases stored inside the hospital, and they are assigned to monthly check and ensure all flammable liquids are in their proper container, appropriately located and properly stored.

3. During interviews on 11/11/14 at 9:00 AM, Staff H, Director of Food Services, acknowledged the finding and stated that they did not have a fire-resistant cabinet for storage of flammables. She stated that no one had ever noticed it or called her attention to the potential hazard.

4. During an interview on 11/11/14 at 9:00 AM, Staff J, Maintenance, acknowledged that the room was only one hour protected and not designed for high hazard storage. He stated that currently, the only flammables cabinet on the campus was in the Maintenance shop.

Based on observation and interview, the facility failed to ensure that six of twelve smoke/fire doors added during a 2011 significant expansion and renovation were equipped with Rabbets, bevels or astragals (smoke resistant groove, bevel or strip along the meeting edges of on one or both doors that overlaps and prevents the spread of smoke or fire into unaffected areas) in areas of new construction in accordance with NAPA 2000, chapter 18.3.7.8, New Health Care Occupancies.

The Centers for Medicare and Medicaid Services has determined that after March 13, 2003, any expansion or major modification in an existing facility involving 50 percent or more that 4,500 square feet of the involved smoke compartment must be surveyed under the 2000 New Life Safety Code. (Appendix I)

18.3.7.8 Rabbets, bevels or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of the door frames in smoke barriers. Positive latching hardware shall not be required. Center mullions shall be prohibited. NAPA 2000 (new).

This deficient practice potentially exposes all staff and patients and fails to protect them from the spread of smoke throughout the structure into unaffected areas. The facility census was eight.

Findings included:

1. Observation on 11/10/14 at 3:30 PM through 4:30 PM showed the following:
- No rabbet, astragal, or bevel was on a pair of fire doors (2-32 and 2-33) located in the north corridor of the second floor medical-surgical wing.
- No rabbet, astragal, or bevel was on a pair of unlabeled fire doors located in the south corridor of the second floor medical-surgical wing.
- No rabbet, astragal, or bevel was on a pair of smoke doors in the second floor Obstetrics corridor (located mid-corridor, just west of the elevators).
- No rabbet, astragal, or bevel was on a pair of smoke doors at the west end of the the second floor Obstetrics corridor.
- No rabbet, astragal, or bevel was on a pair of smoke doors of an east-west corridor of first floor, across from room 1-312 in the medical clinic area.
- No rabbet, astragal, or bevel was on a pair of smoke doors of an east-west corridor of first floor, just outside Exam Room #1 of the medical clinic.
2. During an interview on 03/03/14, Staff DJ, Maintenance stated that the facility completed a significant renovation and expansion in 2011, and several smoke and fire doors were established or replaced. He acknowledged the finding and stated that they had tried metal astragals but they bent easily and prevented doors from closing tightly at the meeting edges. He stated that the rubber strips attached with adhesive with moderate success, but the strips tended to peel off. He stated that the vendor had explained that the edges of the composite doors were engineered to expand in a fire and close the gap between the meeting edges, however, the doors would not react and expand to impede smoke without the added temperature of a fire.

Based upon observation, record review and interview, the facility kitchen failed to store flammable liquids in an approved container suitable for storage of flammable and combustible liquids, in accordance with NFPA 30 and NFPA 99. This deficient practice-the storage of flammables in a moderately hazardous area potentially affects the safety of staff and patients. The patient census was eight.

Findings included:

1. Observations on 11/11/14 at 9:00 AM showed a case of flammable liquid product used for chafing, (heating of casseroles on a food service line) that contained one or more flammable alcohol-based chemicals such as glycol, ethanol, methanol or alcohol on a wire shelf in the kitchen's dry storage room. Approximately 20 containers of the product remained in the 24 count box. Other products stored in the room were combustibles; boxes of paper and plastic ware, paper napkins, utensils, and pre-packaged condiments.

2. Review of facility policy titled Maintenance Standards for Combustible Materials dated 08/2014, showed that the maintenance department is assigned responsibility for the safe storage of all flammable liquids and gases stored inside the hospital, and they are assigned to monthly check and ensure all flammable liquids are in their proper container, appropriately located and properly stored.

3. During interviews on 11/11/14 at 9:00 AM, Staff H, Director of Food Services, acknowledged the finding and stated that they did not have a fire-resistant cabinet for storage of flammables. She stated that no one had ever noticed it or called her attention to the potential hazard.

4. During an interview on 11/11/14 at 9:00 AM, Staff J, Maintenance, acknowledged that the room was only one hour protected and not designed for high hazard storage. He stated that currently, the only flammables cabinet on the campus was in the Maintenance shop.