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Based on observation and interview the facility failed to ensure that doors with self closing devices were held open only by approved devices and closed as designed. The facility census was one Acute Care patient and five Swing Bed patients for a total census of six.

Findings included:

1. Observation on 07/26/23 at 9:30 AM, showed the two doors to a supply room behind the nurses station were held open by plastic wedges. Each of the two doors had a self closing door and were labeled as a fire rated door.

2. During an interview on 07/26/23 at 4:25 PM, Staff N, Assistant Administrator confirmed that the doors had a fire rating and the doors were held open by plastic wedges.

3. Observation on 07/26/23 at 12:45 PM, showed the door to operating room (OR) #1 had tape over a six inch section of the door. During interview upon the observation Staff J, Registered Nurse, stated the tape was on the door to help it keep shut. When it closed it would not remain closed and partially open without the tape.

Based on observation, interview, and document review the facility failed to ensure the heating, ventilation, and air conditioning (HVAC) system provided adequate temperature and humidity for the laboratory. The facility census was one Acute Care patient and five Swing Bed patients for a total census of six.

Findings included:

1 Observation on 07/25/23 at 11:00 AM, showed two portable humidifiers and one portable air conditioner in the laboratory.

2. During an interview on 07/25/23 at 11:15 AM, Staff I, Laboratory Director, stated there were several humidifiers in the laboratory to help with the humidity in the laboratory. The portable air conditioner was necessary to help the laboratory equipment function properly. The building HVAC has shut down in the laboratory a month ago and without the portable air conditioner the analyzer would have shut down.

3. During an interview on 07/25/23 at 11:16 AM, Staff M, laboratory technologist, stated the cold in winter and heat in summer was hard to maintain in the area due to the windows.

4. During an interview on 07/25/23 at 1:00 PM, Staff K, Maintenance Lead, stated he was not sure why the building HVAC could not maintain temperature and humidity. A professional company was asked for a bid to repair the system. The portable air conditioner had been used in the laboratory for approximately four years. The portable humidifiers had been used over the winter and should be in storage for the summer.

5. Review of the blood analyzer documentation showed it needed to operate with a humidity of 30-85% humidity. Documentation for the VITROS 5600 showed it should operate within 15-75%.

Based on record review and interview the facility failed to ensure fire drills were done on the second shift (7PM to 7AM) for four of five quarters reviewed. The facility census was one Acute Care patient and five Swing Bed patients for a total census of six.

Findings included:

1. Review of the fire drill records showed no drill recorded on the second shift for the second quarter of 2023, or the second, third and fourth quarters of 2022.

2. During an interview on 07/26/23 at 8:20 AM, Staff N, Assistant Administrator, stated the main fire response policy did not state fire drills were to be held quarterly for each shift of staff. He did not find any records of a second shift fire drill for those four quarters.

Based on interview and record review the facility failed to ensure that a pre-surgical fire risk assessment was discussed with the surgical team and appropriate interventions were taken based on the risk. The facility census was one Acute Care patient and five Swing Bed patients for a total census of six.

Findings included:

1. During an interview on 07/26/23 at 12:45 PM, Staff J, Registered Nurse (RN), Surgical Services Manager, stated as circulator she assessed the risk of fire prior to each surgery and documented it in the medical record. The result of her assessment was not reported to the surgical team, which usually consisted of three other staff.

2. Review of the surgical log from 06/12/23 to 07/24/23 showed 30 surgeries and Staff J confirmed that she was part of the surgical team and a fire risk would not have been discussed with the team.

3. Review of the facility's policy titled "Fire Safety Perioperative Care Area," dated 09/12/22, showed a fire risk assessment would be performed before each operative or other invasive procedure. Once assessed the RN circulator would report the score or risk level to the team and the team should initiate the actions associated with each of the critical questions that have an affirmative response.