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Based on observation and interview the facility failed to ensure all smoke barrier doors closed tightly when released from the automatic hold open device. This deficient practice affects all patients within the two smoke compartments. The facility census was 27.

Findings included:

1. Observation, during a tour of the facility conducted on 05/23/12 at 1:34 PM, showed the smoke barrier doors, in the west corridor between the medical-surgical unit and the Intensive Care Unit (ICU), when released from the automatic hold open device did not completely separate the two smoke zones. A gap of at least one-fourth inch (1/4 " ) was observed between the edges of both doors.

2. Staff LL, Plant Facilities Manager, confirmed at that time the gap between the doors when closed was greater than one-eighth inch (1/8 " ).

Section 2-3.1.7 of the National Fire Protection Association (NFPA 80) states: the meeting edges of doors swinging in pairs on the pull side shall be 1/8 inch + or - 1/16 inch for steel doors and shall not exceed 1/8 inch for wood doors.

Based on observation and interview the facility failed to provide emergency task illumination for the emergency generator in case of power failure and generator failure. This deficient practice affects all occupants in the facility. The facility census was 27.

Findings included:

1. Observation, during a tour of the facility conducted on the afternoon of 05/23/12 at 2:05 PM, showed the area where the emergency generator is located was not provided with a battery emergency light of at least 1 and ½ hour duration to provide task illumination in the event of mechanical failure of the generator.

2. Staff LL, Plant Facilities Manager, confirmed at that time a battery emergency lighting unit was not provided for the generator.

Section 3-4.2.2.2 of the National Fire Protection Association (NFPA 99) states emergency battery light for task illumination for emergency power at the generator set location shall be provided.

Based on observation and interview the facility failed to ensure all portable medical gas cylinders were individually secured. This deficient practice affects the operation of the facility. The facility census was 27.

Findings included:

1. Observation, during a tour of the facility conducted on the afternoon of 05/23/12 at 2:14 PM, showed eight portable " H " size medical gas cylinders secured to a wall in the medical gas storage room by one chain wrapped around all eight cylinders.

2. Staff LL, Plant Facilities Manager, confirmed at that time the portable medical gas cylinders were not individually secured.

Section 5.1.3.3.2 of the National Fire Protection Association (NFPA 99) states that locations for the central supply systems and the storage of medical gas shall meet the following requirements: (7) be provided with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty from falling.

Based on observation and interview the facility failed to install Alcohol Based Hand Rub dispensers in locations away from an ignition source. This deficient practice affects all occupants in that smoke compartment. The facility census was 27.

Findings included:

1. Observations, during a tour of the facility conducted on the afternoon of 05/23/12 showed the following:

Observation at 1:38 PM, showed an Alcohol Based Hand Rub dispenser, containing 16 ounces of 62% Ethyl Alcohol, mounted to the wall approximately twelve inches above an electrical switch in the soiled linen room adjacent to the Intensive Care Unit.

Observation at 1:42 PM showed an Alcohol Based Hand Rub dispenser, containing 16 ounces of 62 % Ethyl Alcohol, mounted to the wall approximately twelve inches above an electrical switch in room 2448.

Observation at 1:44 PM showed an Alcohol Based Hand Rub dispenser, containing 16 ounces of 62% Ethyl Alcohol, mounted to the wall approximately twelve inches above
an electrical switch in room 2451.

2. Staff LL, Plant Facilities Manager, confirmed at that time the Alcohol Based Hand Rub dispensers were placed on the walls above electrical switches.

Review of CMS regulations showed dispensers shall not be installed in a corridor that is under 6 feet wide; the maximum dispenser capacity for rooms, corridors and areas open to the corridor is 1.2 liters (2.0 liters in suites); the minimum horizontal spacing shall be 4 feet; not more than 37.8 liters shall be mounted within a smoke compartment; storage of quantities greater than 5 gallons (18.9 liters) in a single smoke compartment shall meet the requirements of NFPA 30; dispensers installed directly over carpeted surfaces shall be permitted only in sprinklered smoke compartments; and the dispensers shall not be installed over or directly adjacent to an ignition source. Centers for Medicare & Medicaid Services, 42 CFR Parts 403, 416, 418, 460, 482, 483, and 485, [CMS-3145-IFC], RIN 1038-AN36, Medicare and Medicaid Programs; Fire Safety Requirements Federal Register, Vol. 70, No. 57, Friday, March 25, 2005 42 CFR 483.70 (a) (7).

Based on observation and interview the facility failed to ensure all smoke barrier doors closed tightly when released from the automatic hold open device. This deficient practice affects all patients within the two smoke compartments. The facility census was 27.

Findings included:

1. Observation, during a tour of the facility conducted on 05/23/12 at 1:34 PM, showed the smoke barrier doors, in the west corridor between the medical-surgical unit and the Intensive Care Unit (ICU), when released from the automatic hold open device did not completely separate the two smoke zones. A gap of at least one-fourth inch (1/4 " ) was observed between the edges of both doors.

2. Staff LL, Plant Facilities Manager, confirmed at that time the gap between the doors when closed was greater than one-eighth inch (1/8 " ).

Section 2-3.1.7 of the National Fire Protection Association (NFPA 80) states: the meeting edges of doors swinging in pairs on the pull side shall be 1/8 inch + or - 1/16 inch for steel doors and shall not exceed 1/8 inch for wood doors.

Based on observation and interview the facility failed to provide emergency task illumination for the emergency generator in case of power failure and generator failure. This deficient practice affects all occupants in the facility. The facility census was 27.

Findings included:

1. Observation, during a tour of the facility conducted on the afternoon of 05/23/12 at 2:05 PM, showed the area where the emergency generator is located was not provided with a battery emergency light of at least 1 and ½ hour duration to provide task illumination in the event of mechanical failure of the generator.

2. Staff LL, Plant Facilities Manager, confirmed at that time a battery emergency lighting unit was not provided for the generator.

Section 3-4.2.2.2 of the National Fire Protection Association (NFPA 99) states emergency battery light for task illumination for emergency power at the generator set location shall be provided.

Based on observation and interview the facility failed to ensure all portable medical gas cylinders were individually secured. This deficient practice affects the operation of the facility. The facility census was 27.

Findings included:

1. Observation, during a tour of the facility conducted on the afternoon of 05/23/12 at 2:14 PM, showed eight portable " H " size medical gas cylinders secured to a wall in the medical gas storage room by one chain wrapped around all eight cylinders.

2. Staff LL, Plant Facilities Manager, confirmed at that time the portable medical gas cylinders were not individually secured.

Section 5.1.3.3.2 of the National Fire Protection Association (NFPA 99) states that locations for the central supply systems and the storage of medical gas shall meet the following requirements: (7) be provided with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty from falling.