HospitalInspections.org

Based on observations made on June 20, 2012, the facility failed to ensure that all corridor doors were provided with door hardware which allowed all doors to close to positive latching.

Findings include:

At 11:09 a.m., the corridor door to the Report Room was examined by the surveyor. The door could not be closed to positive latching because there was no latching bolt installed with the door hardware.

Based on the surveyor's observations of June 20, 2012, the surveyor determined that the facility failed to ensure that all self closing doors serving two hour barriers were adequately maintained.

Findings include:

In accordance with Section 19.3.6.3.2 of NFPA 101, 2000 Edition; corridor doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

At 11:15 a.m., the fire barrier doors between the assisted living facility and the CAH were released from the magnetic hold devices by the surveyor. One of the two doors did not close to positive latching when they were released.

Based on observations made by the surveyor during a tour of the interior of the building on June 20, 2012, the surveyor determined not all exit locations were adequately identified with regard to the direction of exiting.

Findings include:

At 11:14 a.m., it was observed that there was an exit sign in the corridor leading past the Emergency Room (ER). There is also a privacy curtain which had been drawn across the width of the corridor just behind the exit sign. When the privacy curtain is drawn across the width of the corridor there is a sign on the curtain which says the following, "Keep Curtain Closed - Do Not Enter". It was understood by the surveyor that the curtain is drawn across the corridor when ER patients need to go to Radiology Department for treatment.

Based on the surveyor's observations which were made on June 20, 2012, it was determined that the facility did not ensure that all exit signs were properly illuminated.

Findings include:

In accordance with 19.2.10 Marking of Means of Egress, means of egress shall have signs in accordance with Section 7.10.

At approximately 10:56 a.m. at the end of the nursing home wing, it was observed that there was a green exit sign above the exit door which lacked illumination within the sign.

Based on surveyor observations made on June 20, 2012, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 25, 1998 Edition and NFPA 13, 1999 Edition.

The findings include:

In accordance with Chapter 2-2.1.2 of NFPA 25, storage of materials shall not block the discharge spray pattern of the sprinklers in the event the system is activated. Further, NFPA 13 and Section 5-7.5.3.1 states that continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section.

1. In accordance with NFPA 13 and Section 5-6.6 Clearance to Storage (Standard Pendent and Upright Spray Sprinklers); the clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater. Exception: Where other standards specify greater minimums, they shall be followed. Further in Annex A-5-6.6 the following is provided: the 18-in. (457-mm) dimension is not intended to limit the height of shelving on a wall or shelving against a wall in accordance with 5-6.6. Where shelving is installed on a wall and is not directly below sprinklers, the shelves, including storage thereon, can extend above the level of a plane located 18 in. (457 mm) below ceiling sprinkler deflectors. Shelving, and any storage thereon, directly below the sprinklers cannot extend above a plane located 18 in. (457 mm) below the ceiling sprinkler deflectors.

At 2:58 p.m. on the top shelve of rack storage, a box marked "Preference" (white perforated paper towels) was stored within at least 6 inches of the horizontal plane of the nearest pendent sprinkler head.

2. In accordance with NFPA 13 and Section 5-7.5.2.1; continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with this section. Regardless of the rules of this section, solid continuous obstructions shall meet the requirements of 5-7.5.1.2. Further the Annex A-5-7.5.2.1 describes that the rules of 5-7.5.2.2 (known as the " Three Times Rule " ) have been written to apply to obstructions where the sprinkler can be expected to get water to both sides of the obstruction without allowing a significant dry shadow on the other side of the obstruction. This works for small noncontinuous obstructions and for continuous obstructions where the sprinkler can throw water over and under the obstruction, such as the bottom chord of an open truss or joist. For solid continuous obstructions, such as a beam, the Three Times Rule is ineffective since the sprinkler cannot throw water over and under the obstruction. Sufficient water must be thrown under the obstruction to adequately cover the floor area on the other side of the obstruction. To ensure this, compliance with the rules of 5-7.5.1.2 is necessary.

At 3:02 p.m. in the kitchen's walk-in freezer, a box of "Chef Pierre Pre Sliced Pies" on an upper shelve was totally blocking the side wall sprinkler.

Based on observations made on June 20, 2012, the facility failed to ensure that all corridor doors were provided with door hardware which allowed all doors to close to positive latching.

Findings include:

At 11:09 a.m., the corridor door to the Report Room was examined by the surveyor. The door could not be closed to positive latching because there was no latching bolt installed with the door hardware.

Based on the surveyor's observations of June 20, 2012, the surveyor determined that the facility failed to ensure that all self closing doors serving two hour barriers were adequately maintained.

Findings include:

In accordance with Section 19.3.6.3.2 of NFPA 101, 2000 Edition; corridor doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

At 11:15 a.m., the fire barrier doors between the assisted living facility and the CAH were released from the magnetic hold devices by the surveyor. One of the two doors did not close to positive latching when they were released.

Based on observations made by the surveyor during a tour of the interior of the building on June 20, 2012, the surveyor determined not all exit locations were adequately identified with regard to the direction of exiting.

Findings include:

At 11:14 a.m., it was observed that there was an exit sign in the corridor leading past the Emergency Room (ER). There is also a privacy curtain which had been drawn across the width of the corridor just behind the exit sign. When the privacy curtain is drawn across the width of the corridor there is a sign on the curtain which says the following, "Keep Curtain Closed - Do Not Enter". It was understood by the surveyor that the curtain is drawn across the corridor when ER patients need to go to Radiology Department for treatment.

Based on the surveyor's observations which were made on June 20, 2012, it was determined that the facility did not ensure that all exit signs were properly illuminated.

Findings include:

In accordance with 19.2.10 Marking of Means of Egress, means of egress shall have signs in accordance with Section 7.10.

At approximately 10:56 a.m. at the end of the nursing home wing, it was observed that there was a green exit sign above the exit door which lacked illumination within the sign.

Based on surveyor observations made on June 20, 2012, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 25, 1998 Edition and NFPA 13, 1999 Edition.

The findings include:

In accordance with Chapter 2-2.1.2 of NFPA 25, storage of materials shall not block the discharge spray pattern of the sprinklers in the event the system is activated. Further, NFPA 13 and Section 5-7.5.3.1 states that continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section.

1. In accordance with NFPA 13 and Section 5-6.6 Clearance to Storage (Standard Pendent and Upright Spray Sprinklers); the clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater. Exception: Where other standards specify greater minimums, they shall be followed. Further in Annex A-5-6.6 the following is provided: the 18-in. (457-mm) dimension is not intended to limit the height of shelving on a wall or shelving against a wall in accordance with 5-6.6. Where shelving is installed on a wall and is not directly below sprinklers, the shelves, including storage thereon, can extend above the level of a plane located 18 in. (457 mm) below ceiling sprinkler deflectors. Shelving, and any storage thereon, directly below the sprinklers cannot extend above a plane located 18 in. (457 mm) below the ceiling sprinkler deflectors.

At 2:58 p.m. on the top shelve of rack storage, a box marked "Preference" (white perforated paper towels) was stored within at least 6 inches of the horizontal plane of the nearest pendent sprinkler head.

2. In accordance with NFPA 13 and Section 5-7.5.2.1; continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with this section. Regardless of the rules of this section, solid continuous obstructions shall meet the requirements of 5-7.5.1.2. Further the Annex A-5-7.5.2.1 describes that the rules of 5-7.5.2.2 (known as the " Three Times Rule " ) have been written to apply to obstructions where the sprinkler can be expected to get water to both sides of the obstruction without allowing a significant dry shadow on the other side of the obstruction. This works for small noncontinuous obstructions and for continuous obstructions where the sprinkler can throw water over and under the obstruction, such as the bottom chord of an open truss or joist. For solid continuous obstructions, such as a beam, the Three Times Rule is ineffective since the sprinkler cannot throw water over and under the obstruction. Sufficient water must be thrown under the obstruction to adequately cover the floor area on the other side of the obstruction. To ensure this, compliance with the rules of 5-7.5.1.2 is necessary.

At 3:02 p.m. in the kitchen's walk-in freezer, a box of "Chef Pierre Pre Sliced Pies" on an upper shelve was totally blocking the side wall sprinkler.