HospitalInspections.org

Based on Observation of the facility and staff interview, the facility failed to ensure that hazardous areas were maintained per the requirements of:
Ref: 2012 NFPA 101 section 19.3.2.1.3, 19.3.6.3.5*
The doors shall be self-closing or automatic-closing.
Findings include:
Observation on 09-26-17 revealed that:
1. At approximately 09:30 hrs the door to dietary office/ dry storage was not self closing when tested.
2. At approximately 09:34 hrs the door to the storage room next to dietary was not self closing when tested..
The above items were verified by the Director of Maintenance at the time of discovery and the Director of Nursing during the exit interview on 09-26-17 at approximately 13:00 hrs.

Based on observation of the facility and staff interview, the facility failed to ensure that the smoke barrier construction was maintained per the requirements of:
Ref: 2012 NFPA 101 section 19.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating
This deficiency has the potential to affect all residents, employees and visitors located in the effected smoke compartments.

Findings include:

Observation on 09-26-17 revealed that at approximately 11:00 hrs the smoke barrier wall next to the cardio pulmonary office had open penetration around some IT cables.
The above item was verified by the Director of Maintenance at the time of discovery and the Director of Nursing during the exit interview on 09-26-17 at approximately 13:00 hrs.