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Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that the doors to hazardous areas were self-closing or automatic-closing. This could place all patients and nursing staff at risk in the event of a fire.

The findings include:

During a tour of the facility with Staff A on 07/31/2018 between 10:30 am and 3:38 pm, observation revealed that the doors of Rooms 127, 129, and 130 in the East Wing; and Clean Linen Room, Soiled Linen Room, 108 Equipment Storage, 110 Equipment Storage, and 183 Kitchenette in the Med Surge Area were not self-closing or automatic-closing.

Ref: 2012 NFPA 101, 19.3.2.1.3

These findings were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that the kitchen vent hood was properly cleaned and inspected. This could place all patients in the vicinity of the kitchen at risk in the event of a fire.

The findings include:

During a tour of the facility with Staff M on 08/01/2018 between 11:05 am and 3:42 pm, record review revealed there were no reports documenting the inspection of the kitchen hood extinguishing system.

Ref: 2012 NFPA 101 Chapter 19 Section 19.3.2.5.1 and Chapter 9 Section 9.2.3; and 2011 NFPA 96 Chapter 11 Section 11.2

These findings were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that the fire alarm system was inspected, tested, and properly maintained. This could place all 12 patients at risk in the event of a fire.

The findings include:

During a tour of the facility with Staff M on 08/01/2018 between 11:05 am and 3:42 pm, record review revealed that the sensitivity test for the smoke detectors had not been completed.

Ref: 2012 NFPA 101 Chapter 19, Section 19.3.4.1, Chapter 9, Section 9.6.2.10.1.1; 2010 NFPA 72 Chapter 14, Section 14.4.5.3.1 & 14.4.5.3.2

The findings were confirmed by Staff M at the time of discovery.

Based on observation, review of facility records, and staff interviews it was determined the facility failed to ensure that this room was identified as a storage room for oxidizing gases by the correct identification. This could place all patients at risk in the event of a fire.

The findings include:

During a tour of the facility with Staff M on 08/01/2018 between 11:05 am and 3:42 pm, observation revealed that the Sleep Study Control Room was not identified as a storage room for oxidizing gases by the proper sign.

Reference: 2012 NFPA 101 Chapter 19 Section 19.3.2.4, Chapter 8 Section 8.7; and 2012 NFPA 99 Chapter 11 Section 11.3.4.1 and 11.3.4.2

These findings were confirmed by Staff Member M at the time of discovery.