HospitalInspections.org

K-18

Based on observation and interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. They shall also resist the passage of smoke. This practice affected all residents, staff, and visitors of the facility. The facility capacity is 25 and the census was 6. Findings include:

Observation on January 5, 2011 at 1:30 pm revealed that the gap between the meeting edges of the double doors in the Acute Care unit was greater than 1/8 inch. This observation was confirmed by Maintenance Staff.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

K-45

Based on observation and interview facility failed to illuminate a means of egress so that failure of any single bulb or fixture would leave the area in darkness and provide enough lighting for the egress to the public way, This practice has the potential to affect all patients, visitors and staff of the facility. The facility census was 6 and a capacity of 25. Findings Include:

Observation of the facility exterior on January 5, 2011 at 1:45 p.m. revealed that four of the ten exit doors of the facility had only single bulb lighting fixtures above the doors and the south exit door of the main corridor the facility is not providing any egress lighting. This observation was confirmed by Maintenance Staff.

NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

K-18

Based on observation and interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. They shall also resist the passage of smoke. This practice affected all residents, staff, and visitors of the facility. The facility capacity is 25 and the census was 6. Findings include:

Observation on January 5, 2011 at 1:30 pm revealed that the gap between the meeting edges of the double doors in the Acute Care unit was greater than 1/8 inch. This observation was confirmed by Maintenance Staff.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

K-45

Based on observation and interview facility failed to illuminate a means of egress so that failure of any single bulb or fixture would leave the area in darkness and provide enough lighting for the egress to the public way, This practice has the potential to affect all patients, visitors and staff of the facility. The facility census was 6 and a capacity of 25. Findings Include:

Observation of the facility exterior on January 5, 2011 at 1:45 p.m. revealed that four of the ten exit doors of the facility had only single bulb lighting fixtures above the doors and the south exit door of the main corridor the facility is not providing any egress lighting. This observation was confirmed by Maintenance Staff.

NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4