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Based on observation and interview the facility failed to maintain all smoke barrier doors in good working order. This deficient practice affects all patients in those smoke compartments. The facility census was 103.

Findings Included:

Observation at 2:17 PM on 07/28/15 during a tour of the facility showed one of the two corridor smoke doors, located near a storage room on the fourth floor, would not completely close when released from the fire alarm system automatic hold open device.

Observation at 2:59 PM on 07/28/15 during a tour of the facility showed one of the two corridor smoke doors, located on the third floor near the dirty utility room, would not completely close when released from the fire alarm system automatic hold open device.

Observation at 3:09 PM on 07/28/15 during a tour of the facility showed both corridor smoke doors, located near patient room 311, would not completely close when released from the fire alarm system automatic hold open device.

Staff RR, Manager Engineering, confirmed at those times the corridor smoke barrier doors would not completely close.

Section 1.3.7.6 of the National Fire Protection Association (NFPA 101) states doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6.

Based on record review and interview the facility failed to conduct fire drills at various times during the day and evening shift. This deficient practice has the potential to affect all occupants in the facility during an emergency situation. The facility census was 103.

Findings Included:

Review of the fire drill records for the previous 12 months, conducted on the afternoon of 07/29/15, showed fire drills for the day shift, 7:00 AM to 3:00 PM, and the evening shift, 3:00 PM to 11:00 PM, were conducted within one hour of the previous drill on that shift.

The fire drills for the day shift were conducted at the following times:
-07/09/14 at 9:35 AM
-10/15/14 at 9:32 AM
-01/14/15 at 9:24 AM
-04/15/15 at 9:39 AM

The fire drills for the evening shift were conducted at the following times:
-08/20/14 at 3:26 PM
-11/12/14 at 3:26 PM
-02/11/15 at 3:34 PM
-05/13/15 at 3:38 PM

During an interview on 07/30/15 at 9:15 AM, Staff XX, Director of Security, confirmed the fire drills for the day and evening shifts had been conducted during the same hour of the day.

Section 19.7.1.2 of the National Fire Protection Association (NFPA 101) states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions.

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 103.

Findings Included:

Observation during a tour of the facility on 07/29/15 at 10:49 AM, showed six "H" size portable medical gas cylinders located in the medical gas room which were not individually secured.

Staff RR, Manager Engineering, confirmed at that time the six portable medical gas cylinders were not individually secured.

Section 5.1.3.3.2 of the 2002 Edition of the Life Safety Code published by 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, record review and interview the facility failed to ensure the relative humidity in one of four operating rooms was maintained at no less than 35 percent. This deficient practice has the potential to affect the health and welfare of any patient undergoing surgery in that operating room. The facility census was 103.

Findings Included:

Observation during a tour of the facility conducted on the afternoon of 07/28/15 at 2:28 PM, showed the relative humidity indicator in operating room #4 was missing from the wall.

Record review of the operating room temperature/humidity log for operating room #4 showed a recording of 0 for the relative humidity for January, 2015 through July, 2015.

Record review of the surgery log indicates the number of surgeries performed in operating room #4 this year as the following:
-January, 21 surgeries performed
-February, 25 surgeries performed
-March, 20 surgeries performed
-April, 16 surgeries performed
-May, 18 surgeries performed
-June, 24 surgeries performed
-July, 23 surgeries performed

During an interview conducted on 07/28/15 at 2:29 PM, Staff RR, Manager Engineering, stated the relative humidity indicator in operating room #4 had not been working and was removed from the room. A relative humidity reading is taken with a sling psychrometer (a hand held device used to measure the relative humidity) once a month.

Section 5-4.1.1 of the 1999 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 99) states the mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Based on observation and interview the facility failed to maintain all smoke barrier doors in good working order. This deficient practice affects all patients in those smoke compartments. The facility census was 103.

Findings Included:

Observation at 2:17 PM on 07/28/15 during a tour of the facility showed one of the two corridor smoke doors, located near a storage room on the fourth floor, would not completely close when released from the fire alarm system automatic hold open device.

Observation at 2:59 PM on 07/28/15 during a tour of the facility showed one of the two corridor smoke doors, located on the third floor near the dirty utility room, would not completely close when released from the fire alarm system automatic hold open device.

Observation at 3:09 PM on 07/28/15 during a tour of the facility showed both corridor smoke doors, located near patient room 311, would not completely close when released from the fire alarm system automatic hold open device.

Staff RR, Manager Engineering, confirmed at those times the corridor smoke barrier doors would not completely close.

Section 1.3.7.6 of the National Fire Protection Association (NFPA 101) states doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6.

Based on record review and interview the facility failed to conduct fire drills at various times during the day and evening shift. This deficient practice has the potential to affect all occupants in the facility during an emergency situation. The facility census was 103.

Findings Included:

Review of the fire drill records for the previous 12 months, conducted on the afternoon of 07/29/15, showed fire drills for the day shift, 7:00 AM to 3:00 PM, and the evening shift, 3:00 PM to 11:00 PM, were conducted within one hour of the previous drill on that shift.

The fire drills for the day shift were conducted at the following times:
-07/09/14 at 9:35 AM
-10/15/14 at 9:32 AM
-01/14/15 at 9:24 AM
-04/15/15 at 9:39 AM

The fire drills for the evening shift were conducted at the following times:
-08/20/14 at 3:26 PM
-11/12/14 at 3:26 PM
-02/11/15 at 3:34 PM
-05/13/15 at 3:38 PM

During an interview on 07/30/15 at 9:15 AM, Staff XX, Director of Security, confirmed the fire drills for the day and evening shifts had been conducted during the same hour of the day.

Section 19.7.1.2 of the National Fire Protection Association (NFPA 101) states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions.

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 103.

Findings Included:

Observation during a tour of the facility on 07/29/15 at 10:49 AM, showed six "H" size portable medical gas cylinders located in the medical gas room which were not individually secured.

Staff RR, Manager Engineering, confirmed at that time the six portable medical gas cylinders were not individually secured.

Section 5.1.3.3.2 of the 2002 Edition of the Life Safety Code published by 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, record review and interview the facility failed to ensure the relative humidity in one of four operating rooms was maintained at no less than 35 percent. This deficient practice has the potential to affect the health and welfare of any patient undergoing surgery in that operating room. The facility census was 103.

Findings Included:

Observation during a tour of the facility conducted on the afternoon of 07/28/15 at 2:28 PM, showed the relative humidity indicator in operating room #4 was missing from the wall.

Record review of the operating room temperature/humidity log for operating room #4 showed a recording of 0 for the relative humidity for January, 2015 through July, 2015.

Record review of the surgery log indicates the number of surgeries performed in operating room #4 this year as the following:
-January, 21 surgeries performed
-February, 25 surgeries performed
-March, 20 surgeries performed
-April, 16 surgeries performed
-May, 18 surgeries performed
-June, 24 surgeries performed
-July, 23 surgeries performed

During an interview conducted on 07/28/15 at 2:29 PM, Staff RR, Manager Engineering, stated the relative humidity indicator in operating room #4 had not been working and was removed from the room. A relative humidity reading is taken with a sling psychrometer (a hand held device used to measure the relative humidity) once a month.

Section 5-4.1.1 of the 1999 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 99) states the mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.