Table of Contents
Bronx Lebanon Special Care Center
Deficiency Details, Certification Survey, September 6, 2011
PFI: 4501
Regional Office: MARO--New York City Area
K18 NFPA 101: CORRIDOR DOORS
Scope: Pattern
Severity: Potential for more than Minimal Harm
Corrected Date: September 30, 2011
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are prohibited by CMS regulations in all health care facilities.
Citation date: September 6, 2011
Based on observation, it was determined that the facility did not ensure that the corridor doors to resident use areas (bathing suites) are free of impediments to closing. This was evidenced by bathing suite room doors on the 3rd , 4th , 5th and 7th floors that were either held open with devices that would impede closing or doors that did not positively latch within its frame.
This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.
The findings include:
On 8/30/11 and 8/31/11 during the annual life safety survey, the following was observed: the door to the bathing suite on the 3rd floor did not latch within its frame when released leaving a inch gap. The bathing suite door on the 4th floor was noted to be tied in the open position to the handrail and when released also did not latch within its frame. 5th and 7th floor bathing suite room doors did not positively latch within their frame. All these doors open to the corridor and are required to at least be able to resist the passage of smoke and to latch within their frames.
In an interview with the Director of Engineering on 8/31/11 at approximately 1:45 pm he stated that all these doors would be adjusted so that they are able to latch within their frames.
711.2 (a) (1)
K38 NFPA 101: EXIT ACCESS
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: September 30, 2011
Exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1
Citation date: September 6, 2011
Section 7.2.1.5.4 states that a latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches (86 cm) and not more than 48 inches (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Based on observation and interview, it was determined that the facility did not ensure that one (1) of two (2) electrically operated main exit/entrance sliding doors on in the 1st floor of the facility (lobby section) was maintained to push open in an emergency with only one releasing operation and that the latch releasing device provided at the exit door is a familiar latch releasing device which could be operated in all lighting conditions.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings are:
During the LSC inspection conducted on 08/31/11 at approximately 1:30pm it was observed that one of the two electrically operated main exit/entrance sliding doors in the lobby section was designed to be pushed open in emergency and had an inscription "In Emergency Push to open". It was also observed that this door was provided with a locking device which is operable with a thumb twist latch/lock releasing device. When tested, the lock engaged and the door could not be pushed manually open as designed. The releasing of the thumb twist locking device and then pushing the door open would require multiple door releasing operations. Also, the thumb twist latch/lock releasing device provided at this door is not a familiar latch releasing device which could be operated even during darkness.
In an interview with the Director of Engineering at the same time he stated that the door had recently been replaced and he was not aware that the vendor did not replicate the original features. Now that this was brought to his attention he would have the thumb twist lock removed as soon as possible.
711.2(a)