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Based on observation, testing, and interview, the provider failed to ensure latching corridor doors for three randomly observed doors to the corridor (room 1201, room 1205, and the ante room to rooms 1208 and 1209) as required. Findings include:

1. Observation and functional testing on 1/21/20 at 2:46 p.m. revealed the corridor door to room 1201 did not close and latch into the door fame as required.

Interview with the the director of facilities and material management at the time of the observation confirmed the observation. He stated he was unaware that door was not properly latching.

The deficiency affected one of numerous requirements for hazardous storage rooms and had the potential to affect 100% of the occupants of that smoke compartment.

2 Observation and functional testing on 1/21/20 at 2:48 p.m. revealed the east corridor door to room 1205 did not close and latch into the door fame as required.

Interview with the the director of facilities and material management at the time of the observation confirmed the observation. He stated he was unaware that door was not properly latching.

The deficiency affected one of numerous requirements for hazardous storage rooms and had the potential to affect 100% of the occupants of that smoke compartment.

3. Observation and functional testing on 1/21/20 at 2:50 p.m. revealed the corridor door of the ante room leading to rooms 1208 and 1209 did not close and latch into the door fame as required.

Interview with the the director of facilities and material management at the time of the observation confirmed the observation. He stated he was unaware that door was not properly latching.

Reference NFPA 101 19.3.6.3.10.

Based on record review and interview, the provider failed to conduct the required number of fire drills to ensure staff were familiar with the provider's fire drill procedures. Findings include:

1. Record review on 1/21/2020 at 4:51 p.m. revealed there was no documentation for night shift (11PM - 7AM) fire drills for quarter three (July, August, September) 2019.

Interview with the director of facilities and material management at the time of the record review confirmed that finding. He was not aware the minimum number of fire drills per the required frequency had not been met for each shift in 2019.

The deficiency had the potential to affect 100% of the occupants of the building.