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Based on observation, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into the corridor of 13 patient rooms, potentially affecting the staff, visitors and as many as 13 resident-patients beds in a facility with a census 39 patients.

Findings included:

1. Observations on 10/30/12 at 10:30 AM showed the door to Room 114 (door number 2936) failed to latch securely when closed into the jamb.

During an interview at the same date and time, Staff BBB stated that the doors are regularly checked on routine preventive maintenance rounds, and called Maintenance for the door latch to be adjusted.

Based on observation and interview, the facility failed to provide secure storage of medical gases in accordance with NFPA 99, (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and the facility census of 39 patients.

Findings included:

1. Observation on 10/30/12 at 2:30 PM showed 10 H-sized cylinders of compressed non-flammable gases, standing upright on the concrete floor and chained in groups of eight to 10 cylinders. Several of the large cylinders were also connected to the manifold for medical gas serving the facility's internal medical gas system. Seven smaller E-size cylinders containing Oxygen and an assortment of 15 smaller cylinders of non-flammable compressed gases were also not secured and either lying on their side or standing upright without neck protection or lacking proper restraint, and could be deadly to staff or other persons in the area if the neck is broken off in a fall. (Highly compressed gasses are liquefied vapors that rapidly expand when oxidized or exposed to ambient air, causing a pressurized escape of the contents through any valve or opening. If the valve or control is knocked off or damaged, it could cause a rapid, uncontrolled release of pressure, which essentially turns the heavy metal cylinder into an unguided torpedo.)

2. During interviews on 11/17/12 at 3:45 PM the Director of Plant Operations stated that they were unclear about which edition of the NFPA 99 code was being enforced, regarding storage of the compressed gas cylinders. He stated they could re-arrange most of the cylinders and were already taking steps to have the empty cylinders removed by the supplier. He stated that the other cylinders for welding and compressed air cylinders for soda machines could be individually restrained by changing the configuration or constructing simple racks to prevent the cylinders from tipping over.

Based on observation, the facility failed to ensure doors to all patient rooms closed and latched securely in accordance with 19.3.6.3.2, to resist the passage of smoke into the corridor of 13 patient rooms, potentially affecting the staff, visitors and as many as 13 resident-patients beds in a facility with a census 39 patients.

Findings included:

1. Observations on 10/30/12 at 10:30 AM showed the door to Room 114 (door number 2936) failed to latch securely when closed into the jamb.

During an interview at the same date and time, Staff BBB stated that the doors are regularly checked on routine preventive maintenance rounds, and called Maintenance for the door latch to be adjusted.

Based on observation and interview, the facility failed to provide secure storage of medical gases in accordance with NFPA 99, (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and the facility census of 39 patients.

Findings included:

1. Observation on 10/30/12 at 2:30 PM showed 10 H-sized cylinders of compressed non-flammable gases, standing upright on the concrete floor and chained in groups of eight to 10 cylinders. Several of the large cylinders were also connected to the manifold for medical gas serving the facility's internal medical gas system. Seven smaller E-size cylinders containing Oxygen and an assortment of 15 smaller cylinders of non-flammable compressed gases were also not secured and either lying on their side or standing upright without neck protection or lacking proper restraint, and could be deadly to staff or other persons in the area if the neck is broken off in a fall. (Highly compressed gasses are liquefied vapors that rapidly expand when oxidized or exposed to ambient air, causing a pressurized escape of the contents through any valve or opening. If the valve or control is knocked off or damaged, it could cause a rapid, uncontrolled release of pressure, which essentially turns the heavy metal cylinder into an unguided torpedo.)

2. During interviews on 11/17/12 at 3:45 PM the Director of Plant Operations stated that they were unclear about which edition of the NFPA 99 code was being enforced, regarding storage of the compressed gas cylinders. He stated they could re-arrange most of the cylinders and were already taking steps to have the empty cylinders removed by the supplier. He stated that the other cylinders for welding and compressed air cylinders for soda machines could be individually restrained by changing the configuration or constructing simple racks to prevent the cylinders from tipping over.