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Based on observation and interview, it was determined the facility was utilizing roller latches on five of six patient room doors in the Intensive Care Unit. The failed practice had the potential to affect all patients, staff and visitors due to the potential spread of fire and smoke due to the potential failure of the roller latches to maintain the doors in the closed position in the event of a fire event. The facility had a census of 38 patients on 06/17/13. This is a recurring deficiency from the Medicare recertification survey conducted 06/23/09 to 06/25/09. The findings follow:

A. On a tour of the Intensive Care Unit on 06/18/13 at 1400, roller latches were observed on the five of six patient room doors (Room #1, Room #2, Room #3, Room #4 and Room #5).

B. In an interview on 06/18/13/ at 1410, the Maintenance Director verified the presence of the observed roller latches.

Based on observation and interview, it was determined the facility did not maintain penetrations for nine of eleven smoke barrier walls with a fire rated material to resist the passage of smoke. The failed practice had the potential to affect all patients, staff and visitors due to the inability of the smoke barrier walls to prevent the passage of smoke and fire through the unsealed penetrations. The facility had a census of 38 patients on 06/17/13. This is a recurring deficiency from the Medicare recertification survey conducted 06/23/09 to 06/25/09. The findings follow:

A. On a tour of the facility with Maintenance Director on 06/19/13 at 0900 unsealed penetrations of the smoke barrier were observed at the following locations:
1) Two unsealed penetrations above the ceiling at the smoke barrier doors located next to Administration.
2) One unsealed penetration of the smoke barrier wall at the smoke barrier doors located across the hall from Administration
3) Two unsealed penetrations of the smoke barrier wall at the smoke barrier doors located near Patient Room 127.
4) Two unsealed penetrations of the smoke barrier wall at the smoke barrier doors in the corridor leading to Lab and Radiology.
5) One unsealed penetration of the smoke barrier wall at the smoke barrier doors near the Intensive Care Unit.
6) Four unsealed penetrations of the smoke barrier wall at the smoke barrier doors near Mammography/Ultrasound.
7) One unsealed penetration of the smoke barrier wall at the smoke barrier doors near the Family Consultation Room in the Emergency Department.
8) Near the Rehabilitation Department, the smoke barrier wall above the ceiling did not extend to the adjacent exterior wall, leaving a gap for the passage of smoke and fire. The wall also had one unsealed penetration.
9) One unsealed penetration of the smoke barrier wall at the smoke barrier doors near the entrance to the Surgery Department.

B. The Maintenance Director verified the unsealed penetrations at the time of observation.

Based on observation and interview it was determined the fire rated doors located at 4 of 11 smoke barrier walls were did not completely close and latch when released from the open position. The failed practice had the potential to affect all patients, staff and visitors because the doors were incapable of preventing the passage of smoke and fire from one side of the smoke wall to the other. The facility had a census of 38 patients on 06/17/13. The findings follow:

A. On a tour of the facility with the Maintenance Director on 06/19/13 at 0900 the fire rated doors at the following locations did not fully close and latch:
1) The smoke barrier wall near Pharmacy.
2) The smoke barrier wall across the hall from Administration.
3) The smoke barrier wall in the corridor leading to Lab and Radiology.
4) The smoke barrier wall near the Rehabilitation Department.

B. The Maintenance Director verified the malfunctioning doors at the time of observation.

Based on Kitchen Hood Suppression System Maintenance Report documentation review and interview it was determined the facility failed to provide maintenance on the kitchen hood fire suppression system every six months as required. The failed practice had the potential to affect all patients, staff and visitors due to the potential spread of fire and smoke originating from an improperly maintained and malfunctioning hood fire suppression system. The facility had a census of 38 patients on 06/17/13. The findings follow:

(Reference NFPA 96, Section 11.2.1)

A. Review of the Kitchen Hood Suppression Maintenance Reports on 06/18/13 at 0855 revealed the kitchen hood fire suppression system received maintenance on 03/22/11 and 04/24/12.

B. In an interview on 06/18/13 at 1040 the Maintenance Director verified the most recent maintenance of the kitchen hood fire suppression system occurred on 04/24/12 and there was no further documentation available for review.