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Based on observation and staff interview, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. These findings constitute an Immediate Jeopardy Situation and could adversely affect egress from the OB unit. This could pose a serious risk for patients by creating a dead-end corridor situation or by trapping patients within the area without staff being aware. The facility was notified of these findings at 2:39 PM on 7/10/2015. The census of the facility at 2:30 PM on 7/10/2015 was 32 patients throughout and 9 patients in the OB Unit. The condition was abated at 4:11 PM on 7/10/2015 as the facility removed the locking device from the 2nd set of doors and arranged the remaining delayed egress lock to activate upon activation of a general fire alarm and sprinkler system activation.

Findings Include:

During the inspection beginning on 11:00 AM on 7/10/2015 the following is noted:

1) The following arrangement is found installed as a "mantrap" are to aid in the prevention of infant abduction from the OB unit. Two sets of cross-corridor doors are installed approximately 8' apart in the corridor between the skilled nursing facility and the OB unit. both sets of doors are provided with a push button to open from the SNF however, egress from the OB unit is arranged with independent 15 second delayed egress locks within the egress path. The delayed egress locks are not arranged to release upon activation of the sprinkler system. The delayed egress locks are not arranged to release upon a general fire alarm. The locks are arranged to release upon simultaneous operation of two local smoke detectors. The delayed egress lock nearest the SNF is not visibly supervised by any staff as it is within the "mantrap" area and is only equipped with a voice intercom to the nurse station. An emergency release switch for both delayed egress locks is provided at the nurse station.

Facility management was present and is aware of these findings.

NFPA Standard: 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. 2000 NFPA 101.7.1.10.1

NFPA Standard: : Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, except delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. 2000 NFPA 101, 18/19.2.2.2.4

NFPA Standard: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

Based on observation and staff interview, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. These findings constitute an Immediate Jeopardy Situation and could adversely affect egress from the OB unit. This could pose a serious risk for patients by creating a dead-end corridor situation or by trapping patients within the area without staff being aware. The facility was notified of these findings at 2:39 PM on 7/10/2015. The census of the facility at 2:30 PM on 7/10/2015 was 32 patients throughout and 9 patients in the OB Unit. The condition was abated at 4:11 PM on 7/10/2015 as the facility removed the locking device from the 2nd set of doors and arranged the remaining delayed egress lock to activate upon activation of a general fire alarm and sprinkler system activation.

Findings Include:

During the inspection beginning on 11:00 AM on 7/10/2015 the following is noted:

1) The following arrangement is found installed as a "mantrap" are to aid in the prevention of infant abduction from the OB unit. Two sets of cross-corridor doors are installed approximately 8' apart in the corridor between the skilled nursing facility and the OB unit. both sets of doors are provided with a push button to open from the SNF however, egress from the OB unit is arranged with independent 15 second delayed egress locks within the egress path. The delayed egress locks are not arranged to release upon activation of the sprinkler system. The delayed egress locks are not arranged to release upon a general fire alarm. The locks are arranged to release upon simultaneous operation of two local smoke detectors. The delayed egress lock nearest the SNF is not visibly supervised by any staff as it is within the "mantrap" area and is only equipped with a voice intercom to the nurse station. An emergency release switch for both delayed egress locks is provided at the nurse station.

Facility management was present and is aware of these findings.

NFPA Standard: 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. 2000 NFPA 101.7.1.10.1

NFPA Standard: : Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, except delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. 2000 NFPA 101, 18/19.2.2.2.4

NFPA Standard: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4