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Based on visual observation the facility failed to assure that all doors within an exit passageway were held open by an approved means. When doors to stairwells, smoke barriers, horizontal exits or hazardous areas are propped open it provides an opportunity to allow fire and/or smoke to flow freely throughout the facility. This deficient practice has the potential to affect 2 of 2 residents.

Findings:

During the facility tour, between the hours of 9:00am and 4:30pm, it was observed, that several fire rated self closing doors were being held open by wood pegs or doors were missing self closing devices.

Interview with Director of Nursing revealed the facility was not aware that the door was being propped open.

Based on visual observation the facility failed to assure that all doors within an exit passageway were held open by an approved means. When doors to stairwells, smoke barriers, horizontal exits or hazardous areas are propped open it provides an opportunity to allow fire and/or smoke to flow freely throughout the facility. This deficient practice has the potential to affect 8 of 10 residents.

Findings:

During the facility tour, between the hours of 9:00am and 4:30pm, it was observed, that several fire rated self closing doors were being held open by wood pegs or doors were missing self closing devices.

Interview with Director of Nursing revealed the facility was not aware that the door was being propped open.

Based on visual observation the facility failed to ensure that all stairs and ramps were supplied with handrails. Handrails shall meet the requirements of NFPA 101 chapter 7.

Findings:

During facility tour between the hours of 9:00am and 4:30 pm it was observed, the facility had no handrails on stairs outside 100 hall and no handrails outside north hall on the ramp.

Interview with Director of Nursing revealed the facility was not aware there were no handrails at these locations.

Based on visual observation the facility failed to provide emergency lighting along the entire length of a corridor. Emergency lighting provides visual assurance where evacuation would be necessary during nighttime hours. The deficient practice had the potential to affect 2 of 2 residents.


Findings:

During the facility tour, between the hours of 9:00am and 4:30pm, it was observed, that there were numerous exit signs that either did not work or did not have the required back-up light in case 1 light goes out. Exit signs are required to have 2 lights in all signs.

Interview with Diret=ctor of Nursing revealed the facility was not aware that the emergency lighting were not working correctly.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 2 of 2 residents.


Findings:

During the facility tour, between the hours of 9:00am and 4:30 pm it was observed, that there are several hazardous area throughout the hospital that have doors that do not positive latch, have no self closing device, or no door at all.

Interview with Director of Nursing revealed the facility was not aware that the doors to the hazardous areas were required to self-close and latch in the frame.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 8 of 10 residents.


Findings:

During the facility tour, between the hours of 9:00am and 4:30 pm it was observed, that there are several hazardous area throughout the hospital that have doors that do not positive latch, have no self closing device.

Interview with Director of Nursing revealed the facility was not aware that the doors to the hazardous areas were required to self-close and latch in the frame.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 2 of 2 residents.
4 of 6 smoke barriers were deficient

Findings:

During the facility tour, between the hours of 9:00am and 4:30 pm it was observed, that there were several penetrations throughout the fire barriers ranging from small holes where wires were run to larger 4 to 5 inch holes.

Interview with Director of Nursing revealed the facility was not aware of the penetrations in the corridor walls that would allow the transfer of smoke from one room to another.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 8 of 10 residents.
2 of 2 smoke barriers were deficient

Findings:

During the facility tour, between the hours of 9:00am and 4:30 pm it was observed, that there were several penetrations throughout the fire barriers.

Interview with Director of Nursing revealed the facility was not aware of the penetrations in the corridor walls that would allow the transfer of smoke from one room to another.

Based on visual observation the facility failed to provide a remote manual stop for the emergency generator. NFPA 110 5.6.5.6 states All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled.

Findings:

During facility tour between the hours of 9:00am and 4:30 pm it was observed, that the facility has no remote manual stop for the emergency generator.

Interview with Director of Nursing revealed the facility was not aware the generator required the remote manual stop.