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Based on facility observation and staff interview and verification, the facility failed to ensure that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas had no impediment to the closing of the doors. The long term acute care hospital at the Gateway location had a capacity of 51 beds with a census of 26 patients at the time of the survey.

Findings included:

On 07/19/10 at 3:45 P.M., the fire alarm sounded for the facility. An announcement over the public address system indicated that a fire alarm was sounded for another area of the hospital building. Observation of facility staff on the seventh floor in reaction to the fire alarm notification was completed. Staff were observed to remove requirement for corridors and close patient room doors.

Tour of the corridors with Staff K while staff were in emergency preparation mode revealed the presence of personal protective equipment (PPE) kits secured to some patient room doors. The kits contained disposable PPE for patients designated to be in isolation due to illness. The kits had two hangers which were hung over the tops of the patient room (corridor) doors. Some of the hangers prevented the room doors from securely latching unless extra effort to latch the doors was applied. Staff K pulled the doors closed to securely latch and informed the floor staff that the doors were to latch.

On 07/21/10 at 11:00 A.M. tour with Staff K of the same corridors revealed that some patient rooms had the PPE isolation kits hanging from the doors. Staff K closed the doors to determine if the hanging kits still prevented the doors from securely latching. Patient rooms 730 and 750 could not be be securely latched due to the isolation kits hanging over the doors. Staff K removed the PPE isolation kits from the doors.

Based on facility observation and staff interview and verification, the agency failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. A minimum of two separate compartments are provided on each floor. The long term acute care hospital at the Gateway location had a capacity of 51 beds with a census of 26 patients at the time of the survey.

Findings included:

On 07/19/10 between the hours of 1:30 P.M. and 4:00 P.M. tour of the facility was completed with Staff K. Review of facility building information revealed the facility was divided into two smoke compartments by a 30 minute smoke barrier wall. Observation of the 30 minute smoke barrier wall revealed the presence of penetrations.

On the conference room side of the smoke barrier wall four penetrations were noted. The four penetrations were noted to range from 2 inches in diameter to approximately 6 inches in diameter. The area noted to be 6 inches in width was approximately 2 inches in height on one end and approximately 3 inches in height on the other end.

Observation on the other side of the smoke barrier wall located in the family waiting area revealed a penetration around a pipe approximately 1 to 2 inches in diameter.

Staff K verified the presence and sizes of the penetrations in the smoke barrier wall.

Based on observation of the facility and staff interview and verification, the facility failed to ensure that exit components (such as stairways) were arranged to provide a continuous path of escape, and to provide protection against fire or smoke from other parts of the building. 8.2.5.2, 19.3.1.1. The long term acute care hospital at the Gateway location had a capacity of 51 beds with a census of 26 patients at the time of the survey.

Findings included:

On 07/19/10 between the hours of 1:30 P.M. and 4:00 P.M. tour of the facility was completed with Staff K. Interview with Staff K revealed that two exit stairwells from the seventh floor discharged directly to the outside of the building at ground level. Observation of Stair B from the seventh floor to exit discharge was completed with Staff K.

When on the stair landing between the second and first floor an obvious odor of cigarette smoke was noted. At the first floor at the point of exit discharge the stairs landing was observed to have a build up dried debris, dust and cigarette butts. Staff K verified that the point of exit discharge was very dirty with combustible debris and smelled strongly of cigarette smoke. Staff K verified the building had a no smoking policy for staff and visitors. Staff K opened the exit door to the public way to find an employee smoking a cigarette outside the exit door.

On 07/21/10, the exit discharge of Stair B was observed with Staff S and K. Staff S verified the exit discharge from inside the building was found to be in unacceptable condition.

Based on facility observation and staff interview and verification the facility failed to ensure that stairways used as exits were in accordance with 7.2 with regard to interior stair exits should be arranged to open from the stair side at not less than every third floor.

19.2.2.2.8*Existing health care occupancies shall be exempt from the re-entry provisions of 7.2.1.5.2. which in part stated there were not to be more than four stories intervening between stories where it is possible to leave the stair enclosure. Clarification for 19.2.2.2.8, Existing health care occupancies stated: *Doors to the enclosures of interior stair exits should be arranged to open from the stair side at not less than every third floor so that it will be possible to leave the stairway at a floor if the fire renders the lower part of the stair unusable during egress or if occupants seek refuge on another floor.

The long term acute care hospital at the Gateway location had a capacity of 51 beds with a census of 26 patients at the time of the survey.

Findings included:

On 07/19/10 between the hours of 1:30 P.M. and 4:00 P.M. tour of the facility was completed with Staff K. Interview with Staff K revealed that two exit stairwells from the seventh floor discharged directly outside the building to the public way. Stair D was identified as one of those stairwells.

Observation of exit stairwell D from the seventh floor to the exit discharge at ground level revealed that re-entry to the building was prohibited from the sixth, fifth, fourth, third and second floors. Each door was locked on each floor which prevented re-entry to the building from the stairwell. Two floors were noted to have construction projects in progress. Staff K verified that each door on floors two through six were locked and that re-entry to the building was not possible.

Based on facility observation and staff interview and verification the facility failed to ensure that exit and directional signs were displayed in accordance with section 7.10 with continuous illumination. The long term acute care hospital at the Gateway location had a capacity of 51 beds with a census of 26 patients at the time of the survey.

Findings included:

On 07/19/10 between the hours of 1:30 P.M. and 4:00 P.M. tour of the facility was completed with Staff K. Interview with Staff K revealed that four exit stairwells from the seventh floor lead to outside the building. Stair E was was observed as one of four stairwells.

Tour of the the stair well revealed that it lead to a corridor on the first floor of the host building. Following the posted exit signage lead to the exit discharge. The door at exit discharge was locked. Staff K pushed on the door but there was no release. Further investigation by Staff K revealed there was a release button located on the right side of the corridor approximately 4 feet prior to the door. Once the button was pushed the door released easily.

Observation of the location of the release button revealed there was no clear signage posted at the release button and no signage on the door to give clear direction to the presence of the release button. Staff K verified the release button could easily be missed and that there was no clear signage posted to give direction for the door release.

Based on facility observation during tour and staff interview and verification, the facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the operation of the detectors. The requirement located in National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. The long term acute care hospital at the Fairhill location had a capacity of 68 beds with a census of 32 patients at the time of the survey.

Findings included:

On 07/20/10 between the hours of 9:30 A.M. and 12:30 P.M. tour of the facility was completed with Staff K. Observation of the second and third floor smoke detector placement revealed the following smoke detectors were placed in close proximity to air flow devices.

Third Floor

1. The smoke detector outside room 3445 was estimated to be approximately 20 to 24 inches from an air flow device.

Second Floor

2. The smoke detector outside the nursing station was estimated to be approximately 12 inches from an air flow device.

3. Two smoke detectors in the pharmacy were estimated to be approximately 18 inches from air flow devices.

4. In A corridor three smoke detectors were estimated to be approximately 12 to 18 inches from an air flow devices.

5. The smoke detector at the north nurses station was estimated to be less than 12 inches from an air flow device.

6. The smoke detector outside room 223 was estimated to be less than 12 inches from an air flow device.

7. The smoke detector outside room 247 was estimated to be less than 12 inches from an air flow device.

Staff K present on tour observed and verified the placement of the smoke detectors on the second and third floors.