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Based on observation and interview the facility failed to ensure doors to all ten patient rooms closed and latched securely in the door frame. This deficient practice affects all patients in the facility. The facility census was 30.

Findings included:

Observation at 9:49 AM on 08/12/14 during a tour of the facility showed the door to patient room eight would not close completely and latch in the door frame when tested.

Staff H, Facilities Administrator, confirmed at that time the door to patient room eight would not latch in the door frame.

Section 19.3.6.3.2 of the National Fire Protection Association (NFPA 101) states doors shall be provided with positive latching hardware. Roller latches shall be prohibited.

Based on observation and interview the facility failed to maintain one of six sets of smoke barrier doors in good working order. This deficient practice affects all patients in the facility. The facility census was 30.

Findings included:

Observation at 9:30 AM on 08/12/14 during a tour of the facility showed one of the two smoke barrier doors, located at the entrance to the Physical Therapy treatment room, would not completely close when released from the fire alarm system automatic hold open device when tested.

Staff H, Facilities Administrator, confirmed at that time only one of the two smoke barrier doors would 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 on at least a quarterly basis for each shift. This deficient practice affects all occupants in the facility. The facility census was 30.

Findings included:

Record review of the facility fire drills for the previous 12 months, conducted on the afternoon of 08/11/14, showed only one fire drill documented as taking place on the 3rd shift, 11:00 PM to 7:00 AM, which occurred on September 30, 2013 at 11:05 PM.

During an interview 08/14/14 at 9:25 AM, Staff H, Facilities Administrator, confirmed the third shift participated in only one fire drill between August of 2013 and July of 2014.

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.