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Based on observation the facility failed to provide corridors that are clear and unobstructed for the complete width of the corridor for 2 of 2 corridors in the facility. This deficiency affects all 13 patients in the facility.

Note: NFPA 101, 2000 edition
NFPA 101:7.3. The width of means of egress shall be measured in the clear at the narrowest point of the exit component under consideration. Exception: Projections not more than 3 1/2 in. on each side shall be permitted at 38 in. and below.

Findings:
During facility tour on July 19, 2011 between 1:00 p.m. and 3:30 p.m. there were clean linen carts, a scale, and other carts blocking the corridor in the following areas. Observations at 1:30 p.m., 2:12 p.m., 2:40 p.m. and 3:12 p.m. revealed that these items were left unattended in the same locations for more than thirty minutes.

1. There were 2 clean linen carts that protruded 21 inches into the corridor by rooms 19 & 26.
2. There were 2 med carts that protruded 20 inches into the corridor by rooms 22 and by the ICU room.
3. There were 2 supply carts that protruded 20 inches into the corridor by rooms 22 and by the ICU room.

Items left in the corridors would prevent the rapid removal of patients in case of a fire or disaster.

Based on visual observation the facility failed to provide smoking regulations that are in accordance with NFPA 101: 19.7.4., for 1 of 1 location. This deficiency affects all patients that use the designated smoking area, 1 patients was observed using the smoking area.

Actual Code:
NFPA 101:18.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited, unless under direct supervision.
(4) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(5) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Findings:

During facility tour on July 19, 2011 between 1:00 p.m. and 3:30 p.m., it was observed that the designated smoking area for the patients did not have a metal container with a self-closing cover device into which ashtrays can be emptied.

Based on observation the facility failed to provide collection receptacles that are too close together or of the proper size in the corridor as per NFPA 101 (Life Safety Code). This deficiency affects 3 of 4 smoke compartments and all 59 residents in the facility.

Note: NFPA 101, 2000 edition:
NFPA 101: 19.7.5.5 Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.

Findings:

During a tour of the facility on July 20, 2011 between 9:00 a.m. and 2:30 p.m. both soiled linen and trash barrels were observed in corridor of halls 100, 300, & 400. A set of receptacles were closer than 64 sq. ft. from each other. These carts were in the same location for more than 30 minutes.

1. A rolling receptacle cart with both soiled linen and trash was observed on the 100 hall by room 108 at 10:25am, 11:05am and 3:00pm

2 A rolling receptacle cart with both soiled linen and trash was observed on the 300 hall by room 305 at 9:48am, 10:18am and 3:00pm

3. Two non rolling receptacles with soiled linen in one and trash in the other was observed on the 400 hall by the Medical Records room at 9:42am, 10:18am and 3:00pm