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Based on observation and interview, it was determined the facility had roller latches installed on 2 (Linen Supply Room and patient Room 315) of 30 corridor doors. Failure to replace roller latches with positive latching devices increased the possibility of closed doors opening during a fire situation, exposing building occupants to the spread of fire and smoke. The failed practice had the potential to affect all current 7 patients on census on 12/01/10, all patients admitted to the facility and all staff and visitors. The findings follow:

A. On a tour of the facility on 12/01/10 at 1215 with the Program Manager, the Linen Supply Room and Patient Room 315 were observed with roller latches.
B. In an interview conducted on 12/02/10 at 1415, the Maintenance Director of the facility's host hospital and the Director of Central Supply verified the roller latches on the corridor doors.

Based on observation and interview, it was determined two of two (Trash Room and Linen Supply Room) rooms in the facility used to store combustibles in quantities considered as hazardous were not protected as hazardous areas because the rooms were not provided with either fire sprinklers or fire rated construction with fire rated doors that were self-closing. Without these protections, fire and smoke have the potential to spread beyond the rooms and affect the safety of building occupants. The failed practice had the potential to affect all 7 patients on current census on 12/01/10, all patients admitted to the facility and all staff and visitors. The findings follow:

A. On a tour of the facility on 12/01/10 at 1215 with the Program Manager, the following observations were made:
1. The door to the Trash Room did not have a fire rating label and thus fire rating of the door could not be verified. The room was not sprinklered. The room contained three trash carts.
2. The door to the Linen Supply Room did not have a fire rating label and thus fire rating of the door could not be verified. The door was not provided with a self-closing device. Observation above the ceiling revealed the corridor wall side of the room did not extend to the roof deck above, which would allow the passage of fire and smoke above the ceiling from the room to the corridor. The room was not sprinklered and contained two metal racks of clean linens and one rack with boxes of adult diapers and antiseptic cleaning wipes.
B. In an interview conducted on 12/01/10 at 1450, the Maintenance Director of the facility's host hospital and the Director of Central Supply verified the observations detailed above.

Based on Fire Drill Manual review and interview, it was determined fire drills conducted in the facility in 2009 and 2010 did not include the transmission of the fire alarm signal for 6 of 8 shifts in 2009 and 3 of 6 shifts in 2010. Transmission of the fire alarm signal was a requirement of fire drills per NFPA 101, Section 19.7.1.2 and protect the safety of patients and other building occupants by verifying fire alarm signals were automatically transmitted to summon the fire department. Failure to automatically summon the fire department extends the response time of the Fire Department to the fire event, placing the building occupants at risk of health and safety. The failed practice had the potential to affect all current 7 patients on census on 12/01/10, all patients admitted to the facility and all staff and visitors. The findings follow:

A. Review of the Fire Drill Manual for the year 2010 on 12/02/10 at 0905 revealed the documentation included an evaluation of the "Alarm" with check boxes indicating "Activated by staff, pull station", "Activated with smoke", "Simulated", or "All clear too early". The alarm was documented as "Simulated" on fire drills conducted on three of six shifts during the year. The shifts with the alarm documented as "Simulated" were on the second shift in the first quarter (02/06/09); and the first shift (07/14/10) and the second shift (08/24/10) of the third quarter.
B. Review of the Fire Drill Manual for the year 2009 on 12/02/10 at 1230 revealed the documentation included an evaluation of the "Alarm" with check boxes indicating "Activated by staff, pull station", "Activated with smoke", "Simulated", or "All clear too early". The alarm was documented as "Simulated" on fire drills conducted on six of eight shifts during the year. The shifts with the alarm documented as "Simulated" were on the first shift (1/15/09) and second shift (03/22/09) in the first quarter; the second shift (05/20/09) in the second quarter; the first shift (07/25/09) and second shift (08/26/09) in the third quarter; and the first shift (10/25/09) in the fourth quarter.
C. In an interview on 12/02/10 at 1500, the Director of Nursing verified there was no further fire drill documentation available for review.

Based on observation and interview, it was determined the facility failed to conduct monthly visual inspections in 2010 for three of three fire extinguishers located in the facility as required by NFPA 10, Section 4-3.1. Failure to perform monthly inspections of fire extinguishers put the health and safety of patients, staff, and visitors at risk because the availability and operational order of the fire extinguishers were not assured in the event of a fire. The failed practice had the potential to affect all 7 patients on current census on 12/01/10, all patients admitted to the facility and all staff and visitors. The findings follow:

A. On a tour of the facility on 12/01/10 at 1215 with the Program Manager, the facility was observed to have a total of three fire extinguishers. All three fire extinguishers had monthly inspection tags for the year 2010 that were blank.
B. In an interview conducted on 12/02/10 at 1430, the Director of Central Supply stated she understood the fire extinguisher service contracted service was completing all required fire extinguisher inspections and verified monthly inspections were not performed on the fire extinguishers.