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Based on observation and staff interview, the facility failed to maintain the one hour fire rated barrier to separate hazardous areas from the rest of the building. This condition would allow smoke and fire to migrate into other parts of the building. The facility had a census of 1 resident.

Findings are:

Observations on 5-22-19 at 11:26 am revealed an unsealed 1 ½ inch hole in the fire rated wall with IT cable going thru it in the boiler room.

During an interview on 5-22-19 at 11:26 am, with Maintenance Staff A, confirmed the opening in the fire rated wall in the boiler room.

Based on observation and staff interview, the facility failed to ensure all the corridor doors in the facility positively latched within the door frames. This condition would not prevent the spread of smoke into the corridor, affecting approximately 31 occupants. The facility had a census of 1 resident.

Findings are:

Observations on 5-22-19 between 12:35 pm and 12:55 pm revealed the following:

1. Room 104 door failed to close within the door frame due to a trash can blocking it open.
2. Room 107 door failed to latch within the door frame.
3. Oxygen Storage room door has a kick down hold open on it.

During an interview on 5-22-19 between 12:35 and 12:55 pm, with Maintenance Staff A, confirmed the findings.

Based on documentation review and interview, the facility failed to conduct fire drills during 1st and 2nd shifts. The deficient practice did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels, which would affect fire procedure response for all occupants. The facility had a census of 1 resident.

Findings are:

Fire drill documentation review on 5-22-19 at 10:49 am, revealed the following:

1. Only two 1st shift fire drills were conducted on 10-17-18 at 1:30 pm and 1-31-19 at 5:15 am in the last year.
2. Only one 2nd shift fire drill was conducted on 4-18-19 at 7:40 pm in the last year.

During an interview on 5-22-19 at 10:49 am, Maintenance Staff A, confirmed the facility failed to conduct the required number of fire drills for each shift.

Based on observation and interview the facility failed to properly utilize power strips for use with nonmedical related items in the patient care vicinity. This deficient practice has the potential to overload the circuit and increase the potential for an electrical fire, affecting approximately 3 occupants. The facility had a census of 1 resident.

Findings are:

Observations on 5-22-19 at 11:45 am revealed, the use of a non-hospital grade power strip in the procedure room used to power a lamp and a cardiac monitor within the patient care vicinity hanging from the cord.

During an interview on 5-22-19 at 11:45 am, with Maintenance Staff A, confirmed the findings and indicated that they were unaware that the items in question had been plugged into the non-hospital grade power strip.

Based on observation and interview, the facility failed to identify and separate empty oxygen cylinders from full ones in storage, allowed storage of combustibles within 20 feet of oxygen cylinders, and failed to provide proper signage on the door of a room used for oxygen storage. These deficient practices could cause confusion when choosing oxygen cylinders in an emergency resulting in an empty cylinder being chosen when a full one was required, and increased the potential for a fire to occur and increases the intensity of a fire. The facility had a census of 1 resident.

Findings are:

Observations on 5-22-19 at 12:52 pm revealed the following:

1. The oxygen storage room between patient rooms 107 and 109 did not have the proper signage on the door to indicate that oxygen was stored within.
2. Combustibles supplies were stored within 20 feet of oxygen cylinders.
3. 12 Size E cylinders were intermixed with full and empty cylinders.
4. No signage was provided indicating as to identify full or empty oxygen cylinders.

During an interview on 5-22-19 at 12:52 pm, Maintenance Staff A confirmed the oxygen cylinders were intermixed and not physically separated, no signage was present to indicate empty or full cylinders and the door failed to have proper signage to indicate oxygen was stored within.

NFPA Standard:

2012 ed.; NFPA 99, 11.3.2.3
Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) Minimum distance of 6.1 m (20 ft)
(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour

2012 ed.; NFPA 99, 11.3.4.1
A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.

2012 ed.; NFPA 99, 11.3.4.2
The sign shall include the following wording as a minimum:
CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING