HospitalInspections.org

Based on visual observation the facility failed to assure that patient doors were not equipped with roller latches. Roller latches are prohibited from being used. 18.3.6.3.9.2 states roller latches can be used if they can keep the doors closed and latched. All doors tested could not keep doors closed.

Findings:

During facility tour between the hours of 8:00am and 12:00pm, it was observed, that all patient/client doors were equipped with roller latches and would not keep the door closed.

Interview with Administrator revealed the facility was unaware the doors could not have roller latches.

Based on visual observation the facility failed to assure that all doors in a required means of egress shall not be equipped with a latch or lock requiring use of a tool or key.

Findings:

During the facility tour between the hours of 8:00am and 12:00pm, it was observed, that several rooms in the facility were equipped with thumb turn latch dead bolts. A key was needed to enter the room and thumb turn latch was used to exit the room.

Interview with Administrator revealed he was unaware on the dead bolts on the doors.

Based on visual observation the facility failed to provide the continuation of the exit discharge to include access to the public way from all required exits. The access provides an easier transition for occupants to evacuate from all exits in the building.
Findings:

During the facility tour, between the hours of 8:00am and 12:00pm, it was observed that the back exit of the facility opened to a fenced in area that requirred a key to exit from the enclosed area. The door was locked with a keyed lock.


Interview with Administrator revealed the facility was not aware that the exit discharge did not continue to the public way due to the pad lock on the gate.ith Administrator revealed he was unaware on the dead bolts on the doors.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas are required to be constructed to resist the passage of smoke.
Findings:

During the facility tour, between the hours of 8:00am and 12:00pm, it was observed, that hazardous rooms in the facility did not have self-clsoing doors.

Interview with Administrator revealed the facility was not aware that the doors to the hazardous areas were required to self-close and latch in the frame

Based on visual observation the facility failed to assure that the fire extinguishers were available every 75 feet. Fire extinguishers are available to extinguish small fire or smoke emergencies. This deficient practice could potentially affect 28 of 28 residents.

Findings:

During the facility tour and the record review, between the hours of 1:00pm and 4:30pm, it was observed, that all portable fire extinguishers were kept inside a locked box on the wall. However, none of the nurses or staff had a key to access the fire extinguishers.

Interview with Administrator revealed the facility was not aware the staff did not have keys to the fire extinguishers.

Based on visual observation the facility failed to provide corridor doors that were not closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room's occupants. The deficient practice had the potential to affect 28 of 28 residents.


Findings:

During the facility tour, between the hours of 1:00pm and 4:30pm, it was observed, that doors to rooms 107,106,205,206,207 and 208 did not positive latch in the frame.

Interview with Administrator revealed the facility was not aware of the door to the Rooms were not latching in the frame.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 28 of 28 residents.
Findings:

During the facility tour, between the hours of 1:00pm and 4:30pm, it was observed, that there were several penetrations found in the fire barrier in multiple locations

Interview with Administrator revealed the facility was not aware of unsealed penetration.