HospitalInspections.org

Based on observation and testing the facility failed to provide smoke barrier doors that closed in a manner that would allow the doors to resist the passage of smoke for 1 of 2 pairs of doors as per National Fire Protection Association-NFPA 101 (Life Safety Code). This deficiency affects 2 of 3 smoke compartments and 24 residents in the facility.

Actual Code: NFPA 101, 2000 edition
NFPA 101:18.3.7 (Subdivision of Building Spaces)
18.3.7.8 Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of the door frame in smoke barriers. Positive latching hardware shall not be required. Center mullions shall be prohibited.

Findings:

During a test of the fire alarm system on October 21, 2010 between 12:00 p.m. and 4:00 p.m., the smoke barrier door on the East hall next to the Exam room was observed not to be closing completely. The top of the door is dragging on the frame.

Based on observation the facility failed to provide corridors that are clear and unobstructed for the complete width of the corridor for 1 of 3 corridors as per NFPA 101. This deficiency affects all 24 residents in the facility.

Note: NFPA 101:7.3.2 " Measurement of Means of Egress. " The width of means of egress shall be measured in the clear at the narrowest point of the exit component under consideration. Exit access should be arranged to avoid any obstructions to the convenient removal of non-ambulatory persons carried on stretchers or on mattresses serving as stretchers.

Findings:

During facility tour on October 21, 2010 between 12:00 p.m. and 4:00 p.m., the facility had a bed in the corridor by the electrical room 4 on the west hall.

Based on observation, the facility failed to exercise the generator under load each month for 1 of 1 generator as per NFPA 99:3-4.4.1.1 and NFPA 110. This deficiency affects all 24 residents in the facility.

Note: NFPA 110:6-4.1 Level 1 and Level 2 EPSSs, including all components, shall be inspected weekly and shall be exercised at least once monthly under load, for a minimum of 30 minutes of not less than 30 percent of the EPS nameplate rating.

Findings:

Review of the generator log on October 21, 2010 between 12:00 p.m. and 4:00 p.m. revealed that there was no documentation of a load test been done or the generator was not being exercised each month for at least 30 minutes under load. The facility was only able to provide a load bank test done for each year. Interview with the facility maintenance director during the survey process and at the exit interview verified that no additional documentation of a monthly load test was available.