HospitalInspections.org

Based on observations and testing of at least 30 corridor doors revealed that 2 do not comply with NFPA 101 "The Life Safety Code" 2000 Edition Section 19.3.6.1. If these rooms do not have corridor doors that positively latch, a fire could open the door and spread beyond the room of origin, negatively impact all 16 residents, any visitors and staff.

Findings include:
Observations and testing of 30 corridor doors, during the facility tour on September 10, 2013, between 9:45 am and 12:15 pm, by surveyor 03006, revealed that:

1) The new roll down door over the therapy reception room corridor window did not positively latch, and

2) The door closer on the inactive leaf of the double doors into Home Health Office had been removed so the corridor doors did not operate properly and latch.

The Director of Maintenance verified these findings during the facility tour and during the exit conference.

Based on observations of the exterior exit doors it was determined that the exit signage is not in accordance with "The Life Safety Code" NFPA 101 (2000 edition) sections 7.10.1.1. This deficient practice could create confusion in the visitors and staff in an emergency situation when in the ambulance garage.

Findings include:
Observations of the exterior exit doors, during the facility tour on September 10, 2013, between 9:45 am and 12:15 pm, by surveyor 03006, revealed that the exit from the ambulance garage is not signed.

The Director of Maintenance verified these findings during the facility tour and during the exit conference.

Based on observations it was determined that the automatic fire sprinkler system is not complete in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems and NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.5. This deficient practice could allow the a fire to progress above the ceiling system into an unprotected concealed space and negatively effect all 16 patients, any visitors and staff of the facility.

Findings include:
Observations during the facility tour on September 10, 2013, between 9:45 am and 12:15 pm, by surveyor 03006, revealed that ceiling tiles are missing in the IT closet and in Central Supply.

The Director of Maintenance verified these findings during the facility tour and during the exit conference.

Based on observations and testing of at least 30 corridor doors revealed that 2 do not comply with NFPA 101 "The Life Safety Code" 2000 Edition Section 19.3.6.1. If these rooms do not have corridor doors that positively latch, a fire could open the door and spread beyond the room of origin, negatively impact all 16 residents, any visitors and staff.

Findings include:
Observations and testing of 30 corridor doors, during the facility tour on September 10, 2013, between 9:45 am and 12:15 pm, by surveyor 03006, revealed that:

1) The new roll down door over the therapy reception room corridor window did not positively latch, and

2) The door closer on the inactive leaf of the double doors into Home Health Office had been removed so the corridor doors did not operate properly and latch.

The Director of Maintenance verified these findings during the facility tour and during the exit conference.

Based on observations of the exterior exit doors it was determined that the exit signage is not in accordance with "The Life Safety Code" NFPA 101 (2000 edition) sections 7.10.1.1. This deficient practice could create confusion in the visitors and staff in an emergency situation when in the ambulance garage.

Findings include:
Observations of the exterior exit doors, during the facility tour on September 10, 2013, between 9:45 am and 12:15 pm, by surveyor 03006, revealed that the exit from the ambulance garage is not signed.

The Director of Maintenance verified these findings during the facility tour and during the exit conference.

Based on observations it was determined that the automatic fire sprinkler system is not complete in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems and NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.3.5. This deficient practice could allow the a fire to progress above the ceiling system into an unprotected concealed space and negatively effect all 16 patients, any visitors and staff of the facility.

Findings include:
Observations during the facility tour on September 10, 2013, between 9:45 am and 12:15 pm, by surveyor 03006, revealed that ceiling tiles are missing in the IT closet and in Central Supply.

The Director of Maintenance verified these findings during the facility tour and during the exit conference.