HospitalInspections.org

Based on visual observation the facility failed to provide free egress from all required exits. Access to an unobstructed exit provides occupants with a sense of security to remain calm when an emergency occurs. These gates should be part of their electronic locking system unless they are at least 50 feet from the building and meet the same requirements in the detention chapter referencing 22.2.7.2. The deficient practice had the potential to affect 9 of 9 residents.



Findings:

During the facility tour and interview with staff, between the hours of 1:00pm and 4:00pm it was observed, that outside smoking area for clients has a marked exit on a gate that is padlocked. This gate should be on a maglock system and release on activation of the fire alarm.

Interview with Administrator revealed the facility was unaware the gate needed to be on the maglock system and attached to the fire alarm.

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 9 of 9 residents.
3 of 3 smoke barriers were deficient.

Findings:

During the facility tour, between the hours of 1:00pm and 4:00pm, it was observed, that penetrations were found above all fire doors in facility.

Interview with Administrator revealed the facility was not aware of unsealed penetration.

Based on visual observation, the facility failed to assure that the policy on smoking required all smoking areas to be supplied with a metal, self-closing container. Cigarette butts shall be extinguished in an approved container in order to prevent accidental combustion. This deficient practice could potentially affect 9 of 9 residents.

Findings:

During the facility tour, between the hours of 1:00pm and 4:00pm it was observed, that the facility had plastic ashtrays in smoking area and one ashtray contained a plastic bag cigarette butts were discarded into. Smoking areas had no non-combustible ashtrays and no metal containers with self-closing covers into which ashtrays can be emptied

Interview with Administrator revealed the facility was not aware the containers in the smoke area did not meet the requirements.