HospitalInspections.org

Based on observation and staff interview, the facility failed to maintain means of egress as required by the 2012 NFPA 101, Life Safety Code. Failure to maintain means of egress as required could result in injury or death during an emergency. The deficiency affected one (1) of four (4) smoke compartments. The findings were:

Observation on 6/25/2019 at 10:15 AM in the corridor outside the dining room revealed a wheelchair partially obstructing the corridor. Further observation revealed when measured the unobstructed corridor width was 51 inches.

Interview with the facility maintenance staff at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility director of operations at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section: 19.2.3.4 (4)(a)
.

Based on observation and staff interview, the facility failed to maintain egress doors in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain egress doors as required could result in injury or death during an emergency. The deficiency affected one (1) of four (4) smoke compartments. The findings were:

Observation on 6/25/2019 at 10:30 AM revealed the kitchen door leading to the dining room was double locked. A dead bolt lock was located approximately 42" above the floor. Further observation revealed that when locked the door required more than one operation to open. This deficiency was also cited during the 11/19/2015 survey.

Interview with the facility maintenance staff at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility director of operations at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Sections: 19.2.2.1; 7.2.1.5.10.2
.

Based on observation and staff interview, the facility failed to maintain hazardous areas in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 80, Standard for Fire Doors and Other Opening Protectives. Failure to maintain hazardous areas as required could result in injury or death during an emergency. The deficiency affected one (1) of four (4) smoke compartments. The findings were:

1. Observation on 6/25/2019 at 10:50 AM at the oxygen storage room revealed that the self-closing fire door failed to latch when tested.

Interview with the facility maintenance staff at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility director of operations at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section: 8.3.3.3.1
2010 NFPA 80, Section: 5.2.4.2(8)

2. Observation on 6/25/2019 at 11:10 AM in the laundry room revealed a central laundry greater than 100 square feet. Further observation revealed two fire doors which lacked self-closing devices. Additionally, one of the fire doors was propped open by a bag of laundry.

Interview with the facility maintenance staff at the time of observation acknowledged the deficiency, and indicated awareness of the requirement.

Interview with the facility director of operations at the time of exit acknowledged the deficiency.

REF: 2012 NFPA 101, Section: 19.3.2.1.3