HospitalInspections.org

Based on visual observation the facility failed to provide 2 corridor doors with positive latching devices, this deficiency if not corrected could have the potential to cause harm to the 31 patients in the building.

Findings: During tour of building on 6-3-2011 at 2:30 p.m. the restroom doors by rooms 11 and 12 were observed with dead bolt latching devices installed on them. These restrooms are attached to patient rooms. Doors protecting corridor openings are to be provided with positive latches.

Based on visual observation the facility failed to maintain the 1 of 2 sets of smoke barrier doors, this deficiency if not corrected could have the potential to cause harm to the 16 patients in the building.

Findings: During tour of building on 6-3-2011 at 11:45 a.m. the smoke barrier doors by room 108 were observed, while testing the fire alarm, releasing from the magnetic holding device. However, the doors bounced off of the top of the door frame and did not stay completely closed. Also, these doors did not have a astragal that resisted the passage of smoke.
Doors in smoke barrier walls shall be self closing and resist the passage of smoke, latching is not required.

Based on visual observation the facility is using a patient room for a medical file room. This deficiency if not corrected could have the potential to cause harm to the 31 patients in the building.

Findings: During tour of building on 6-3-2011 at 2:45 p.m. the new medical file room (which was previously a patient room) was observed storing large amounts of combustible materials and not being protected with 1 hour fire walls and a 45 minute door and closure.

Based on visual observation the facility failed to provide a key override for the magnetic locks located on the 2nd means of egress cross corridor doors, also a pad lock was observed on the gate leading from the building to the public way. This deficiency if not corrected could have the potential to cause harm to the 31 patients in the building.

Findings: During tour of building on 6-3-2011 at 3:00 p.m. the cross corridor doors were observed having magnetic locking devices installed, and did not have a key override for staff to unlock in case the doors did not release on fire alarm activation. The only method of unlocking was a number key pad that has to have a code entered in for release. All staff are required to carry keys to any doors with mag locks. Also, the gate leading from the nursing home to the back parking lot was observed with a pad lock.

Based on visual observation the facility failed to provide means to secure oxygen cylinders. This deficiency if not corrected could have the potential to cause harm to the 16 patients in the facility.

Findings: During tour of building on 6-3-2011 at 11:30 a.m. the oxygen cylinders being stored in the supply room across from the conference room were observed not being braced or secured.
Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on visual observation the facility failed to provide a generator annunciator panel in a area that is readily observable by staff. This deficiency if not corrected could have the potential to cause harm to the 16 patients in the building.
During facility tour on 6-3-2011at 12:00 p.m. the required generator annunciator panel was observed not installed at a work site readily observable by staff. NFPA 110 requires staff to monitor the generator engine in case of a malfunction that may prevent it from starting in case of a power failure.

Based on visual observation the facility failed to provide 2 corridor doors with positive latching devices, this deficiency if not corrected could have the potential to cause harm to the 31 patients in the building.

Findings: During tour of building on 6-3-2011 at 2:30 p.m. the restroom doors by rooms 11 and 12 were observed with dead bolt latching devices installed on them. These restrooms are attached to patient rooms. Doors protecting corridor openings are to be provided with positive latches.

Based on visual observation the facility failed to maintain the 1 of 2 sets of smoke barrier doors, this deficiency if not corrected could have the potential to cause harm to the 16 patients in the building.

Findings: During tour of building on 6-3-2011 at 11:45 a.m. the smoke barrier doors by room 108 were observed, while testing the fire alarm, releasing from the magnetic holding device. However, the doors bounced off of the top of the door frame and did not stay completely closed. Also, these doors did not have a astragal that resisted the passage of smoke.
Doors in smoke barrier walls shall be self closing and resist the passage of smoke, latching is not required.

Based on visual observation the facility is using a patient room for a medical file room. This deficiency if not corrected could have the potential to cause harm to the 31 patients in the building.

Findings: During tour of building on 6-3-2011 at 2:45 p.m. the new medical file room (which was previously a patient room) was observed storing large amounts of combustible materials and not being protected with 1 hour fire walls and a 45 minute door and closure.

Based on visual observation the facility failed to provide a key override for the magnetic locks located on the 2nd means of egress cross corridor doors, also a pad lock was observed on the gate leading from the building to the public way. This deficiency if not corrected could have the potential to cause harm to the 31 patients in the building.

Findings: During tour of building on 6-3-2011 at 3:00 p.m. the cross corridor doors were observed having magnetic locking devices installed, and did not have a key override for staff to unlock in case the doors did not release on fire alarm activation. The only method of unlocking was a number key pad that has to have a code entered in for release. All staff are required to carry keys to any doors with mag locks. Also, the gate leading from the nursing home to the back parking lot was observed with a pad lock.

Based on visual observation the facility failed to provide means to secure oxygen cylinders. This deficiency if not corrected could have the potential to cause harm to the 16 patients in the facility.

Findings: During tour of building on 6-3-2011 at 11:30 a.m. the oxygen cylinders being stored in the supply room across from the conference room were observed not being braced or secured.
Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on visual observation the facility failed to provide a generator annunciator panel in a area that is readily observable by staff. This deficiency if not corrected could have the potential to cause harm to the 16 patients in the building.
During facility tour on 6-3-2011at 12:00 p.m. the required generator annunciator panel was observed not installed at a work site readily observable by staff. NFPA 110 requires staff to monitor the generator engine in case of a malfunction that may prevent it from starting in case of a power failure.