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Based on observations made on July 24, 2013, the facility failed to maintain the fire resistance rating of a two-hour separation wall. This deficiency has the potential to affect all patients, staff and visitors on the main floor level.

The findings include:

The two-hour fire barrier located adjacent to the corridor for the Mammography and X-Ray was examined at 8:02 a.m. on July 24, 2013. The barrier above the set of opposite swing fire doors in the corridor had two round open penetrations that had not been sealed with a rated fire block material.

Based on observations made on July 24, 2013, the facility failed to assure that there was no impediment to closing a corridor door. This deficiency has the potential to affect a very limited number of patients, staff and visitors on the main level.

The findings include:

In accordance with NFPA 101 and Section 19.3.6.3.3, hold-open devices that release when the door is pushed or pulled shall be permitted. Further, Annex A.19.3.6.3.3 states that doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Patient room 211 was examined at 7:30 a.m. on July 24, 2013. The room was occupied during the observation and a wastebasket was in use to prop the corridor door open that had the potential to impede it from closing.

Based on observations made on July 24, 2013, the facility failed to assure that the magnetic hold open device was interconnected to the fire alarm system correctly. This deficiency has the potential to affect more than a very limited number of staff and visitors to the basement.

The findings include:

The set of corridor fire doors to the basement receiving room were examined at the time of the fire alarm test conducted at 8:11 a.m. on July 24, 2013. The active door of the set was equipped with a hold open device with electronic controls. The fire alarm was activated and the door device did not release to automatically close the fire door as required. When the fire alarm was reset the fire door did release and close.

Based on observations made on July 24, 2013, the facility failed to assure that a fire door protecting an exit stairway closed and latched each time it was used. This deficiency has the potential to affect more than a very limited number of patients, staff and visitors.

The findings include:

The one hour rated fire door at the main level of the exit stairway from the basement that opens onto the ambulance entryway was exercised at 7:48 a.m. on July 24, 2013. The door did not latch each and every time that it was exercised by the surveyor.

Based on observations made on July 23, 2013, the facility failed to assure that portable fire extinguishers were properly installed on a hanger or in a cabinet. This deficiency has the potential to affect more than a very limited number of staff in the basement.

The findings include:

Portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses per section 1-6.7 and 1-6.10 of NFPA 10, 1998 Edition. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor.

The basement receiving room was examined on the afternoon of July 23, 2013. Between 3:51 and 3:54 p.m., two portable fire extinguishers were observed to be placed on the floor level of this room.

Based on observations made on July 23 and 24, 2013, the facility failed to assure that oxygen cylinders were secured against being knocked down or falling over and failed to limit the amount of oxygen stored outside of a dedicated oxygen storage room to less then 300 cubic feet per smoke compartment. These deficiencies have the potential to affect more than a very limited number of patients, staff and visitors on both the main and basement levels.

The findings include:

Freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down per sections 8-3.1.11.2(h) and 4-3.5.2.1(b27) of NFPA 99, 1999 Edition.

1. The main oxygen storage/manifold room was examined at 4:10 p.m. on July 23, 2013. Four "D" size cylinders and five "MD" type cylinders of oxygen were observed to be freestanding in this room.

Up to 300 cubic feet of nonflammable medical gas (12 "E" size cylinders) associated with resident care may be located outside of a dedicated oxygen enclosure room in a single smoke compartment as long as they are properly secured per CMS Survey and Certification letter 07-10 dated January 12, 2007. If placed in a corridor they shall be placed so as not to obstruct the use of the corridor.

2. The clean utility room across from the gift shop was examined at 7:36 a.m. on July 24, 2013. This room was being used for the storage of "E" size cylinders. Nineteen "E" size cylinders, comprising approximately 456 cubic feet, were observed to be stored in the clean linen room. This amount exceeds the 300 cubic feet amount that may be stored outside of a dedicated oxygen storage room.

Based on observations made on July 24, 2013, the facility failed to maintain the fire resistance rating of a two-hour separation wall. This deficiency has the potential to affect all patients, staff and visitors on the main floor level.

The findings include:

The two-hour fire barrier located adjacent to the corridor for the Mammography and X-Ray was examined at 8:02 a.m. on July 24, 2013. The barrier above the set of opposite swing fire doors in the corridor had two round open penetrations that had not been sealed with a rated fire block material.

Based on observations made on July 24, 2013, the facility failed to assure that there was no impediment to closing a corridor door. This deficiency has the potential to affect a very limited number of patients, staff and visitors on the main level.

The findings include:

In accordance with NFPA 101 and Section 19.3.6.3.3, hold-open devices that release when the door is pushed or pulled shall be permitted. Further, Annex A.19.3.6.3.3 states that doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Patient room 211 was examined at 7:30 a.m. on July 24, 2013. The room was occupied during the observation and a wastebasket was in use to prop the corridor door open that had the potential to impede it from closing.

Based on observations made on July 24, 2013, the facility failed to assure that the magnetic hold open device was interconnected to the fire alarm system correctly. This deficiency has the potential to affect more than a very limited number of staff and visitors to the basement.

The findings include:

The set of corridor fire doors to the basement receiving room were examined at the time of the fire alarm test conducted at 8:11 a.m. on July 24, 2013. The active door of the set was equipped with a hold open device with electronic controls. The fire alarm was activated and the door device did not release to automatically close the fire door as required. When the fire alarm was reset the fire door did release and close.

Based on observations made on July 24, 2013, the facility failed to assure that a fire door protecting an exit stairway closed and latched each time it was used. This deficiency has the potential to affect more than a very limited number of patients, staff and visitors.

The findings include:

The one hour rated fire door at the main level of the exit stairway from the basement that opens onto the ambulance entryway was exercised at 7:48 a.m. on July 24, 2013. The door did not latch each and every time that it was exercised by the surveyor.

Based on observations made on July 23, 2013, the facility failed to assure that portable fire extinguishers were properly installed on a hanger or in a cabinet. This deficiency has the potential to affect more than a very limited number of staff in the basement.

The findings include:

Portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses per section 1-6.7 and 1-6.10 of NFPA 10, 1998 Edition. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor.

The basement receiving room was examined on the afternoon of July 23, 2013. Between 3:51 and 3:54 p.m., two portable fire extinguishers were observed to be placed on the floor level of this room.

Based on observations made on July 23 and 24, 2013, the facility failed to assure that oxygen cylinders were secured against being knocked down or falling over and failed to limit the amount of oxygen stored outside of a dedicated oxygen storage room to less then 300 cubic feet per smoke compartment. These deficiencies have the potential to affect more than a very limited number of patients, staff and visitors on both the main and basement levels.

The findings include:

Freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down per sections 8-3.1.11.2(h) and 4-3.5.2.1(b27) of NFPA 99, 1999 Edition.

1. The main oxygen storage/manifold room was examined at 4:10 p.m. on July 23, 2013. Four "D" size cylinders and five "MD" type cylinders of oxygen were observed to be freestanding in this room.

Up to 300 cubic feet of nonflammable medical gas (12 "E" size cylinders) associated with resident care may be located outside of a dedicated oxygen enclosure room in a single smoke compartment as long as they are properly secured per CMS Survey and Certification letter 07-10 dated January 12, 2007. If placed in a corridor they shall be placed so as not to obstruct the use of the corridor.

2. The clean utility room across from the gift shop was examined at 7:36 a.m. on July 24, 2013. This room was being used for the storage of "E" size cylinders. Nineteen "E" size cylinders, comprising approximately 456 cubic feet, were observed to be stored in the clean linen room. This amount exceeds the 300 cubic feet amount that may be stored outside of a dedicated oxygen storage room.