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Based on observations, the facility failed to ensure that all use areas are separated from corridors as required. Section 19.3.6.1, Exception #6 allows spaces other than sleeping rooms, treatment rooms and hazardous areas to be open to the corridor provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system installed in accordance with 19.3.4, and (b) each space is protected by automatic sprinklers, and (c) The space is arranged not to obstruct access to required exits. Smoke detectors are required to be interconnected with the fire alarm system, spaced no more than 15 feet from any wall and no more than 30 feet apart.

THE FINDINGS INCLUDE:

Observations while touring the facility on 10/11/12 revealed that the three (3) Bader Five Unit open sitting areas, labeled BA 521 Lounge 198, BA 533 Lounge 284 and FA 503 Cafeteria 530, are open to the corridor and are not protected by smoke detectors.

This was observed by facility mainteance staff during the survey tour and reviewed with facility staff at the summary of survey findings.

Based on observations, the facility failed to ensure that there are no impediments to the closing of doors protecting corridor openings. NOTE: Hold-open devices that release when the door is pushed or pulled (no manual unlatching or releasing action necessary to close) are permitted, such as friction catches or magnetic catches.

THE FINDINGS INCLUDE:

Observations while touring the facility on 10/10/12 (at 12:10 PM) revealed that the Patient room doors at MA741, MA742, 740, MA 744 were all wedged open with a towel hung above the top of the door's active leaf preventing the active from setting in the door frame. Each room's in-active leaf was swung into the room in the open position.

Facility maintenance staff removed the impediment (towel above the door), and lubricated the latching hardware so that doors closed and latched properly.
This was observed by facility mainteance staff during the survey tour and reviewed with facility staff at the summary of survey findings.

Based on observations and confirmed by staff, it was observed that corridor doors are not maintained as required. Section 18.3.6.5 states openings in other than smoke compartments containing patient bedrooms, miscellaneous openings such as mail slots, pharmacy pass-through windows, laboratory pass-through windows, and cashier pass-through windows shall be permitted to be installed in vision panels or doors without special protection, provided that the aggregate area of openings per room does not exceed 80 in.2 (520 cm2) and the openings are installed at or below half the distance from the floor to the room ceiling. Section 18.3.6.3.6 states Dutch doors shall be permitted where they conform to 18.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.

THE FINDINGS INCLUDE:

- During the morning hours of 10/15/12 while touring the facility, it was observed that the pharmacy door located on the 3rd floor level is equipped with a pass through opening. The opening however is approximately 18" x 24" (432 square inches) and does not meet the size limitation to qualify as a pass through opening. The door must therefore meet the requirements of a Dutch door. The door is not equipped with an astragal, a rabbet, or a bevel at the meeting edges.

This was confirmed by the Facilities Director during the building tour.

Based on observations, the facility failed to ensure that the means of egress is maintained properly.
Chapter 19, section 19.2.2.2.4 states:
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.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
section 19.2.2.2.5 states:
Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.

THE FINDINGS INCLUDE:

- Observations while touring the facility on 10/11/12 revealed that the three (3) Bader Five stair doors (labeled BD 5S1 stair 235, BA 5S1 stair 190, and BA 5S2 stair 186) are equipped with keyed cylinder door locks. Nursing staff interviewed on 10/11/12 were unable to provide keyed unlocking and rapid removal through any of the doors. The nurse manager indicated that facility policy directed staff to contact security and security would respond with the key to unlock the stair door.

Note, on 10/12/12 facility maintenance staff installed new cylinder keyed locks and provided Bader Five staff with keys.
This was observed by facility maintence staff during the survey tour and reviewed with facility staff at the summary of survey findings.