HospitalInspections.org

Based on observations the facility failed to provide doors with self-closing or automatic-closing in accordance with 19.2.2.2.6. This condition has the potential to affect about 50% of the residents and staff.

Finding include:

While inspecting smoke barrier walls on November 5, 2013 at 11:00 a.m., the maintenance supervisor and the surveyor observed a door in the smoke barrier walls, located next to the nursing station did not close properly.

This deficient practice has the potential of affecting 2 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This condition affected 25% of the residents and staff or 1of 3 smoke compartments.

Findings include:

While inspecting hazardous areas on November 5, 2013 at 10:30 a.m., the maintenance person and the the surveyour found the one hour enclosure for the fuel fired Generator Room had a penetrations around the sprinkler pipe in the common wall to the hospital.

This deficient practice has the potential of affecting 1 of 3 smoke compartments.

The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observation, the facility failed to provide readily accessible exit discharge as per NFPA 101 19.2.1, NFPA 101 chapter 7.7.1, 7.1.6.4, 7.1.10.1. and all states letter Ref: S&C -07-05. This condition had the potential to affect 50% of the residents and staff.

Findings Include:

While inspecting exits on November 5, 2013 at 11:00 a.m., the maintenance person and surveyor found 1 of the 5 required exits to be inaccessible. The exit from the patient wing corridor lacked an all weather surface to the public way.

7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or
other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

7.1.6.4* Slip Resistance.
Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.

7.1.10.1*
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.

This deficient practice has the potential of affecting 1 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required fire drill documentation as per NFPA 101 chapter 18.7.1.2, 19.7.1.2. This condition had the potential to affect 100% of the residents and staff.

Findings include:

While reviewing fire drill documentation on November 5, 2103 at 11: 45 p.m., the surveyor observed the facility did not provide fire drill information for past fire drills including date, time, what shift, and personnel attending the fire drill. Fire drill documentation did not show what shift the fire drills were conducted on.

This deficient practice has the potential of affecting 3 of 3 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.