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Based on observation and interview, the facility failed to ensure 1 of 1 sets of double doors entering the laundry room, a hazardous area, latched into the door frame. This deficient practice was not in a resident care area but could affect any number of staff.

Findings include:

Based on observation with the Director of Environmental Services on 10/28/13 at 12:15 p.m., the laundry room was equipped with double corridor doors. One door was equipped with a manual latching device that would latch into the door frame and the remaining door was designed to latch into the stationary door. Each door could not latch automatically, and independent of the other door, into the door frame. This was confirmed by the Director of Environmental Services at the time of observation.

Based on observation and interview, the facility failed to ensure 2 of 2 sprinklered elevator equipment rooms were provided with an automatic means for disconnecting the main line power supply. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the elevator machine room. This deficient practice could affect patients in the 2008 surgical addition near the elevator rooms.

Findings include:

Based on observations with the Director of Environmental Services on 10/28/13 at 11:15 a.m., both elevator equipment rooms were provided with sprinkler coverage. Based on an interview with the Director of Environmental Services at the time of observations, the elevator equipment in both rooms lacked a shunt trip to automatically disconnect the main line power supply just before, or upon, sprinkler activation.

3.1-19(b)