HospitalInspections.org

Based on observation the facility failed to provide a wall that has at least a two-hour fire resistance rating that separates the hospital from the business occupancies in the rest of the facility. This deficiency affects the 1of 3 separation walls and all 7 patients in the facility.

Findings:

During facility tour on April 17, 2013 between 8:00 a.m. and 10:30 a.m. it was observed that the separation wall on the south side of the facility was not separated from the rest of the facility by a fire barrier wall having not less than a 2-hour fire resistance rating. The entire complex is sprinklered and has a construction type of II (000). This wall has a piece of broken drywall above the separation doors.

Based on observation the facility failed to provide doors that close, latch, or resist the passage of smoke for 4 of 43 doors in the facility as per NFPA 101 (Life Safety Code). This deficiency affects all 7 patients in the facility.

Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, "Existing Health Care Occupancy, " 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4-in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required.

Findings:

During tour of the facility on April 17, 2013 between 8:00 a.m. and 10:00 a.m., the door to the following rooms did not latch, close or resist the passage of smoke.

1. 102, 106 & 201 had gaps between the door and the frame. This gap would allow smoke to pass between the room and the corridor.
2. The door to the Therapy Gym and the OT ADL room is not positive latching.
3. The door to the Staff lounge and the DON ' s office has dropdown door stops on them. These stops would prevent the door from being pulled shut in case of an emergency.

Based on review of documentation the facility failed to provide routine inspection, testing and maintenance of the sprinkler system as per NFPA 25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems) for 1 of 1 system. This deficiency could affect all 7 patients in the facility.

Note: NFPA 25, 1998 Edition:
NFPA 25, Chapter 2, " General " 2-1 This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.

Findings:

During review of the sprinkler system documentation on April 17, 2013 between 8:00 a.m. and 10:30 a.m. it was revealed that facility failed to have all devices on the sprinkler system routinely inspected or tested at the proper intervals or failed to document such actions.

Interview with the facility administrator during the survey process and at the exit interview verified that no additional documentation of the sprinkler system inspection was available.

Based on observation the facility failed to provide collection receptacles that are of the proper size in the corridor as per NFPA 101 (Life Safety Code). This deficiency affects 5 of 5 receptacles, in 1 of 2 smoke compartments and all 7 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 April 17, 2013 between 8:00 a.m. and 10:30 a.m. observation revealed that there were 5 soiled linen and the trash collection containers are 32 gallons in capacity in the alcove on the south hall.