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Based on observation it was determined that the facility had not ensured all hazardous areas were separated from the corridors by an enclosure. Lack of enclosure would allow smoke and heat to infiltrate the corridors in case of fire and would potentially affect all residents. The census was 25 according to facility documentation.

The findings include:

Observation on April 12, 2011 at 4:27 p.m. disclosed that the door to the ICU medical supply storage room was not self-closing. The designated use of the area had been changed to storage from a physicians' sleeping room and was located adjacent to and across the corridor from the liquid oxygen transfilling room.

The condition was observed by the surveyor and the maintenance director.

NFPA 101 reference:
18.3.2 Protection from Hazards.
18.3.2.1* Hazardous Areas.
Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

7.2.1.8 Self-Closing Devices.
7.2.1.8.1*
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Based on observation and staff interview it was determined that the facility had not ensured that the liquid oxygen (LOX) transfilling room had proper safety placards displayed for the room. The census was 25 as shown on facility documentation.

The findings include:

Observation on April 12, 2011 at 4:20 p.m. disclosed that the entry way door to the transfilling room did not have a placard that stated: "No Smoking, Transfilling Room". The maintenance director stated at the time of the observation that the room had been put into service approximately May 2009 and the proper signs needed to be placed.

The condition was observed by the maintenance director and the surveyor.