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Based on observation, testing, and interview, the provider failed to maintain four of four sets of smoke doors in the hospital. When in the closed position all doors left a gap of approximately one inch at the top. Findings include:

1. Observation on 8/28/19 from 8:00 a.m. to 11:00 a.m. revealed four sets of self-closing smoke doors that separated the corridors of the hospital. Testing of all those doors revealed one leaf would catch on the other and leave approximately a one inch gap at the top of the doors.

Interview at the time of the observations with the environmental services manager confirmed those findings. She stated she did not always check to ensure the doors closed properly on a fire drill.

The deficiency affected four of four smoke compartment locations required to maintain separation from use areas.

Based on random observation, testing, and interview, the provider failed to maintain two of five separate hazardous areas (patient room 22 and the nurse supply storage room) as required. Findings include:

1. Random observation on 8/28/19 from 8:00 am. to 11:30 a.m. revealed:
*Patient room 22 was used for storage.
*The nurse supply room was used for patient supply storage.
*The doors to those rooms were not self-closing.
*All rooms were at least 200 square feet in size.

Interview at the time of the observation with the environmental services manager confirmed those findings. She stated the patient room had been used for storage for several years. She was unaware the nurses' supply room was considered a hazardous storage areas.

The deficiency affected two of numerous requirements for hazardous storage rooms.

Based on observation and interview, the provider failed to maintain proper containment of soiled linens. The soiled utility room was used for holding soiled linens overnight and was not provided with an automatic door closer. Findings include:

1. Observation on 8/28/19 at 9:00 a.m. revealed the soiled linen utility room was approximately seventy-five square feet in area. It was used to hold five full containers of thirty to forty gallon soiled linens in cloth totes on wheeled platforms. The door to that room did not have a self-closer. Interview with the environmental services manager at the time of the observation confirmed that finding. She was unaware why so many containers of soiled linen were stored in that room.

The deficiency affected two of numerous requirements for soiled linen storage rooms.

Based on observation, testing, and interview, the provider failed to provide a routine maintenance check for:
*Four of four smoke barrier doors as required.
*One of one ninety-minute fire-rated door as required. Findings include:

1. Observation on 8/28/19 from 8:00 a.m. to 11:00 a.m. revealed four sets of self-closing smoke doors that separated the corridors of the hospital. Testing of all those doors revealed one leaf would catch on the other and leave approximately a one inch gap at the top of the doors.

Interview with the environmental services manager at the time of the observation confirmed that finding. She stated they did not have those doors on any kind of preventative maintenance checklist. Nor did she have any of the doors including the ninety-minute fire-rated door between the nursing home and the hospital on a routine preventative maintenance program. She relied on staff to tell her or the maintenance department if a door was not not working or latching properly.

The deficiency had the potential to affect all doors located throughout the facility and the occupants.

Based on observation and interview, the provider failed to maintain three feet of clear working space in front of the electrical panels in one of one hazardous area (the laundry's soiled linen room). Findings include:

1. Observation on 8/28/19 at 10:00 a.m. revealed the electrical panels in the laundry's soiled linen room were completely blocked by several large wheeled carts of soiled linen. There was only a path of travel through that room. A minimum of three feet of clear working space was not provided to any electrical panel in that room.

Interview at the time of the above observations with the environmental services manager confirmed those findings. She stated she was aware of the minimum distance of three feet of clear working space in front of electrical panels. She stated they did not have the room to store all the soiled linen from their facility and other contracted facilities.

The deficiency had the potential to affect 100% of the facility's occupants.

Based on observation and interview, the provider failed to ensure temporary wiring (extension cords) were not used for:
*One of one infant warmer in the equipment supply room by the nurses station.
*One of one operating room (OR).
Findings include:

1. Observation on 8/28/19 at 10:30 a.m. of the patient equipment storage room revealed an extension cord plugged into an infant warmer. Interview with the environmental services manager at that time confirmed that finding. She stated they used extension cords throughout the facility as there were not enough outlets. She was not aware extension cords were not an acceptable means of permanent wiring and should only be used on a temporary basis.

Continued observation on that same day at 1:30 p.m. revealed seven extension cords in the operating room. Interview with the surgical technician at that same time confirmed that finding. She stated they needed to use those cords to plug in equipment used in the operating room. She was not aware extension cords could not be used in the facility. They should be removed from outlets and properly stored when not in-use to avoid damage and potential circuit arcing.

This deficiency has the potential to affect critical patient equipment.

Based on observation and interview, the provider failed to display precautionary signs as a warning to the public for one of one approximately 8000 liter liquid oxygen storage container in the back parking lot. Findings include:

1. Observation on 8/28/19 at 11:00 a.m. revealed an approximately 8000 liter liquid oxygen storage container located to the west of the building in the parking lot. On that container was a small faded sign that read "NO SMOKING." Interview with the environmental services manager at that same time confirmed that finding. She stated she was not aware of the signage requirement, and the only sign was that small one on the tank itself.

The NFPA 99 oxygen signage requirements were as follows:
"11.3.4 Signs.
11.3.4.1 A precautionary sign, readable from a distance of 1.5 m [meters] (5 ft), shall be displayed on each door or gate of the storage room or enclosure.
11.3.4.2 The sign shall include the following wording as a minimum:
CAUTION:
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING."

This deficiency affected all occupants of the facility and surrounding area.