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Based on observation and interview the facility failed to assure all doors to hazardous areas remained closed tightly in the door frame. This deficient practice affects all patients in that smoke compartment. The facility census was 37.

Findings included:

1. Observation, during a tour of the facility conducted on the afternoon of 09/10/13 at 1:38 PM showed the self-closing device on the door to the Soiled Utility room, a hazardous area, on the 3rd floor Intensive Care Unit (ICU) would not completely close and latch in the door frame.

2. Observation, during a tour of the facility conducted on the afternoon of 09/10/13 at 2:03 PM showed the self-closing device on the door to the Soiled Utility room, a hazardous area, on the 3rd floor Medical-Surgical Unit would not completely close and latch in the door frame.

3. Staff HH, Plant Operations, confirmed at that time the self-closure devices on the doors to the 2 Soiled Utility rooms would not completely close the doors.

Section 19.3.2.1 of the National Fire Protection Association (NFPA 101) states: Any hazardous area shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing system shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Based on observation and interview the facility failed to maintain all corridors free of obstructions. This deficient practice affects all patients within that smoke compartment. The facility census was 37.

Findings included:

Observations during a tour of the facility conducted on the afternoon of 09/10/13 showed the following on the 3rd floor Medical-Surgical Unit:

1. Three medication carts were observed at 1:52 PM against the wall in the exit corridor between patient rooms 352 and 354.

2. Two vital sign monitors, both plugged into an electrical wall outlet, were observed at 1:53 PM against the wall in the exit corridor between patient rooms 348 and 350.

3. Two crash carts were observed at 1:54 PM against the wall in the exit corridor between patient rooms 356 and 358.

During an interview on 09/10/13 at 1:55 PM, Staff DD, Unit Secretary, stated that these items are placed in the exit corridor when not being used by the facility staff.

Section 7.1.10.1 of the National Fire Protection Association (NFPA 101) states: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and interview the facility failed to ensure all portable medical gas cylinders were individually secured. This deficient practice affects the operations of the facility. The facility census was 37.

Findings included:

1. Observations during a tour of the facility conducted on the afternoon of 09/10/13 at 3:35 PM showed 4 portable medical gas cylinders of Nitrogen secured to a wall by 1 chain, another 5 gas cylinders of Nitrogen secured to a wall by 1 chain, 4 portable medical gas cylinders of Nitrous Oxide secured to a wall by 1 chain and another 3 gas cylinders of Nitrous Oxide secured to a wall by 1 chain in the 1st floor medical gas room.

2. Staff HH, Plant Operations, confirmed at that time the portable medical gas cylinders were not individually secured.

Section 5.1.3.3.2 of the National Fire Protection Association (NFPA 99) states that locations for the central supply systems and the storage of medical gas shall meet the following requirements: (7) be provided with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty from falling.

Based on document review and interview the facility failed to conduct weekly inspections of the emergency generator. This deficient practice affects all occupants of the facility. The facility census was 37.

Findings included:

1. Review of the facility generator testing documents, conducted on the morning of 09/10/13, showed there was no documentation indicating a weekly inspection of the emergency generator was being conducted by the facility staff.

2. During an interview on 09/10/13 at 1:14 PM, Staff HH, Plant Operations stated that no one has been conducting a weekly inspection of the emergency generator.

Section 8.4.1 of the National Fire Protection Association (NFPA 101) states the emergency power system (EPSS) including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.