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Based on observation, schematic review and interview during facility tour it was determined this facility failed to ensure the doors of hazardous areas were equipped with automatic or self-closing devices. This had the potential to affect all patients utilizing these areas. The patient census was 12 at the time of the survey.

Findings include:

Facility schematic review on 01/09/17 revealed the Bio-med and the office adjacent to the east of the Bio-med room were constructed as hazardous areas to meet the one hour fire rating. Facility tour took place with staff members Z1, Z2 and Z3 on 01/10/17 from approximately 9:00 AM to 4:00 PM. During tour of the first floor central supply area, specifically the Bio-med room and the office adjacent to the east of the Bio-med room, observation was made of the doors to each room lacking a self-closing or automatic closing device.

This finding was confirmed by staff Z1 and Z3 during tour.

Based on observation and staff interview during facility tour, it was determined the facility failed to install, inspect, and maintain portable fire extinguishers in accordance with NFPA 10. This had the potential to affect all patients who utilize this facility. The total patient census was 12 at the beginning of the survey.

Findings include:

Facility tour took place with staff members Z1, Z2 and Z3 on 01/10/17 from approximately 9:00 AM to 4:00 PM. During facility tour observation was made of several portable fire extinguishers placed in wall cabinets, some which were recessed into the wall. All those observed lacked identification tags for immediate and proper identification of the fire extinguisher location.

These finding were verified by staff Z1, Z2 and Z3 during facility tour.

Based on observation and staff interview during facility tour, it was determined the facility failed to construct and maintain the one half hour smoke barrier in accordance with NFPA 101. This had the potential to affect all patients who utilize this facility. The total patient census was 12 at the beginning of the survey.

Findings include:

Facility tour took place with staff members Z1, Z2 and Z3 on 01/10/17 from approximately 9:00 AM to 4:00 PM. During facility tour on Level 3, observation was made at the north end smoke barrier (med/surg) of an approximate five foot by three foot section of the smoke barrier missing from the back wall of the restroom.

During tour of Level 1 within the office adjacent to the restroom on the NW corner of the smoke barrier (between the cardio and lab), observation was made of penetrations around a heating and ventilation duct and also conduits and a sewer line.

These findings were verified by staff Z1 and Z3 during facility tour.