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Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to (i) one exit access door propped open with a wedge; (ii) corridor double doors in one location not positively latching; and (iii) lack of positive latching hardware on one exit access corridor door. This affected 3 of 10 smoke compartments in the facility.The facility had a census of 40 patients with a licensed capacity of 56 beds.

Findings include

Item 1. During a tour of the facility with Staff C (director of plant operations) on 7/25/2011, Surveyor 12316 observed at 1:55 pm, that the exit access corridor door of the Dialysis Room 233 on the 2nd Floor was propped open with a wedge, which is an impediment to closing of the door.

Item 2. During a tour of the facility with Staff C (director of plant operations) on 7/26/2011, Surveyor 12316 observed that (i) at 9:42 am, one leaf of the double doors to the Locker Room suite on the 1st Floor did not fully close and latch; and (ii) at 10:05 am, that the corridor door to the Cafeteria on the 1st Floor did not have a positive latching hardware to keep the door closed and latched, nor was the Cafeteria protected with smoke detectors to consider as a space open to corridor in accordance with NFPA 101 19.3.6.1

The above deficiency was acknowledged by the director of plant operations at the time of discovery, and confirmed with Staff A (chief executive officer), Staff B (director of quality management), Staff V (regional senior director of operations), and Staff F (chief executive officer) at the exit conference on 7/27/2011 at 11:30 am.

Based on observation and staff interview, the facility failed to ensure safety to patients due to one corridor not kept clear and unobstructed. This affected 1 of 10 smoke compartments in patient sleeping/use areas. The facility had a census of 40 patients with a licensed capacity of 56 beds.

Findings include

During a tour of the facility with Staff C (director of plant operations) on 7/25/2011, Surveyor 12316 observed at 11:20 am that six compressed " E " size oxygen gas cylinders were stored in corridor causing obstruction in the means of egress on the 3rd Floor.

On 7/25/2011, Surveyor 12316 observed at 2:35 pm that two Rubbermaid trash receptacles were stored in exit access corridor adjacent to the Storage in the Pharmacy causing obstruction. The exit access corridor was not clear and unobstructed.

Both deficiency items stated above were acknowledged by the director of plant operations at the time of discovery, and confirmed with Staff A (chief executive officer), Staff B (director of quality management), Staff V (regional senior director of operations), and Staff F (chief executive officer) at the exit conference on 7/27/2011 at 11:30 am.

Based on observation and staff interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to automatic, supervised sprinkler system not maintained in accordance with the requirements of NFPA 13 (1999) and 25 Standards 1998 edition. This deficient practice affected the entire facility. The facility had a census of 40 patients with a licensed capacity of 56 beds.

Findings include

During a tour of the facility with Staff C (director of plant operations) between 7/25 -7/27/2011, Surveyor 12316 observed in the following 5 locations that there were either missing escutcheon plates, or dirty sprinkler heads, or lack of sidewall sprinkler heads at the bottom of elevator pits, not more than 2 ft above the pit floor.

(i) On 7/25/2011 at 2:05 pm, the escutcheon plate of one sprinkler head near the exit access corridor door of the Special Care Unit on the 2nd Floor was missing;
(ii) On 7/25/2011 at 2:42 pm, one sprinkler head in corridor adjacent to the medical equipment Storage and Stairwell 2 on the 3rd Floor was dirty;
(iii) On 7/25/2011 at 3 pm, one sprinkler head in corridor adjacent to the Patient Room 310 and smoke doors was dirty;
(iv) On 7/26/2011 at 9:29 pm, the escutcheon plate of one sprinkler head in the Reception Closet on the 1st Floor was missing; and
(v) When interviewed on 7/27/2011 at 11:20 am, the director of plant operations stated that there were no sprinkler heads installed at the bottom of the hydraulic elevator hoistway as required by NFPA 13 (1999) 5-13.6.1

The above deficiency was acknowledged by the director of plant operations at the time of discovery, and confirmed with Staff A (chief executive officer), Staff B (director of quality management), Staff V (regional senior director of operations), and Staff F (chief executive officer) at the exit conference on 7/27/2011 at 11:30 am.

Based on observation and interview, the facility failed to ensure safety to patients due to trash receptacles of more than 32 gal capacity not stored in a room protected as a hazardous area in accordance with NFPA 101 19.7.5.5 requirement. This deficient practice affected 1 of 10 smoke compartment of the facility. The facility had a census of 40 patients with a licensed capacity of 56 beds.

Findings include

During a tour of the facility with Staff C (director of plant operations) on 7/25/2011, Surveyor 12316 observed at 2:30 pm that two trash Rubbermaid receptacles of capacity greater than 32 gallons were stored in exit access corridor in the Pharmacy, and not stored in a room with smoke partitions and self-closing doors, and protected with automatic extinguishing system.

The above deficiency was acknowledged by the director of plant operations at the time of discovery, Staff A (chief executive officer), Staff B (director of quality management), Staff V (regional senior director of operations), and Staff F (chief executive officer) at the exit conference on 7/27/2011 at 11:30 am.

Based on observation and staff interview, the facility failed to ensure safety to patients due to compressed gas oxygen cylinders not stored in an enclosure in accordance with NFPA 99 8-3.1.11.2. This affected 1 of 10 smoke compartments in patient sleeping/use areas. The facility had a census of 40 patients with a licensed capacity of 56 beds.

Findings include

During a tour of the facility with Staff C (director of plant operations) on 7/25/2011, Surveyor 12316 observed at 11:20 am that six compressed " E " size oxygen gas cylinders in individual tip-proof carts were stored in corridor across the south Exit Stair adjacent to Pharmacy on the 3rd Floor, and not in a secured room or closet of non-combustible construction. Five of six O2 cylinders were full and one cylinder was empty.

The above deficiency was acknowledged by the director of plant operations at the time of discovery, and confirmed with Staff A (chief executive officer), Staff B (director of quality management), Staff V (regional senior director of operations), and Staff F (chief executive officer) at the exit conference on 7/27/2011 at 11:30 am.