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Based on observation, operational testing, and interview the facility failed to maintain doors that protect corridor openings. Failure to maintain corridor doors could allow smoke and dangerous gases to pass freely in a fire event. This deficient practice affected only staff and visitors on the date of survey. The facility is licensed for 25 hospital beds with a census of 11 on the day of survey.

Findings Include:

During the facility tour on August 13, 2015 at approximately 11:00 AM, observation and operational testing of the door to the housekeeping office revealed the door would not close properly when released from the magnetic hold open device allowing an approximately 1 inch gap between the the edge of the door and the door frame. The door was not capable of resisting the passage of smoke. When asked, the Maintenance Supervisor stated the facility was unaware of the door not closing properly.

Actual NFPA standard:
19.3.6.3.1*
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

Based on observation and operational testing, the facility failed to ensure that all doors in smoke barriers were self-closing and resisted against the passage of smoke. The deficient practice affected no patients, staff and visitors. The facility has a capacity for 25 beds with a census of 11 on the day of survey.

Findings Include:

During the facility tour on August 13, 2015 at approximately 10:30 AM, observation of the cross corridor doors near the administration office and the kitchen failed to close completely when released from the magnetic hold open device leaving an approximately 1 inch gap between the doors. When asked, the Maintenance Supervisor stated the facility was unaware of the doors not closing properly.

Actual NFPA standard:
19.3.7.5
Openings in smoke barriers shall be protected by fire-rated glazing; by wired glass panels and steel frames; by substantial doors, such as 13/4-in. (4.4-cm) thick, solid-bonded wood core doors; or by construction that resists fire for not less than 20 minutes. Nonrated factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door shall be permitted.
Exception: Doors shall be permitted to have fixed fire window assemblies in accordance with 8.2.3.2.2.

Based on observation and interview the facility failed to ensure exit signage was continuously illuminated. This deficient practice could confuse evacuation in a dark smoke filled corridor. This deficient practice affected staff members on the date of survey. The facility is licensed for 25 hospital beds with a census of 11 on the day of survey.

Findings Include:

During the facility tour on August 13, 2015 at approximately 1:30 PM, observation and reveled multiple exit signs located in the main surgery suite corridor were not operational. When asked, the maintenance supervisor stated the facility was unaware the exit sign were not working properly.

Actual NFPA standard:
19.2.10 Marking of Means of Egress.
19.2.10.1
Means of egress shall have signs in accordance with Section 7.10.
Exception: Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons.

7.10.5 Illumination of Signs.
7.10.5.1* General.
Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

Based on observation and interview, the facility did not ensure that means of egress was maintained free from obstructions. Failure to provide exit access free of obstructions could prevent the safe evacuation during an emergency. This deficient affected patients that were located in the surgery suite as well as staff members on the day of survey. The facility is licensed for 25 hospital beds with a census of 11 on the day of survey.

Findings Include:

During the facility tour on August 13, 2015 at approximately 1:00 PM, observation revealed approximately 12 plastic tote storage boxes stored in the corridor of the surgery suite corridor. When asked, the Maintenance Supervisor stated other agencies that utilize the surgery suite at the end of the week will bring the supplies needed in the plastic containers and store the containers in the corridor until completed with the surgery suite. The Maintenance Supervisor stated the facility was unaware the storage containers blocked the means of egress.

Actual NFPA standard:
7.1.10 Means of Egress Reliability.
7.1.10.1*
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.1.10.2 Furnishings and Decorations in Means of Egress.
7.1.10.2.1
No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.