St Marys Center Inc

REPEAT DEFFICIENCY
Based on observation and staff interview, the facility did not ensure that corridor doors are designed and maintained to resist smoke/fire and are kept free of impediment to closing.

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings are:

On 12/29/10, the following corridor doors were observed impeded from closing by wood chocks or food tray tables, chairs and garbage cans at the following area: nurses Station on the 2nd , 3rd and 4th floor, Room #s 507,506,501,405, 302,303 and 206,207.

On 12/29/10, at approximately 2:30 p.m. the Facility's Manager was interviewed and he stated these items would be immediately removed and staff would be in-serviced on the issue of using inappropriate devices to hold doors open.

The same issue was cited in the previous standard survey conducted on 12/29/09, the facility's plan of Correction indicated that the issue would have been corrected by 1/6/10, however as the issue continued to exist as of 12/29/10.

711.2(a) (1)
NFPA 101, 2000. Chapter 19

Based on observation and interview, it was determined that the facility did not ensure that all stairway enclosures were kept free of storage that would potentially impede emergency egress. This was evidenced by numerous plastic bags of soiled linen and trash being temporarily stored inside the stairway landing on the 2nd and 3rd floor.

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include:
On December 29, 2010 it was observed that sections of the 2nd and 3rd floors stairway enclosures were being used for storage of numerous bags of soiled linen and trash. Approximately 4-6 plastic bags filled with bed sheets towels, blankets and trash were observed stored inside the stair way enclosure on the 2nd and 3rd floors landing. The storage of soiled linen and trash linen or other items in the stairway would not ensure the safe usage of the exit corridors, in case of fire or other emergency.
In an interview with the Facility's Manager on 12/29/10 at approximately 12:15 pm he stated that the soiled utility rooms on the units do not have enough space to keep all the soiled materials on the units. He further stated that the housekeeping staff use the stairway enclosure as temporary storage until all the soiled materials have been gathered on that floor and then they are taken down to the storage location in the basement. He then stated that the items would be removed immediately and the practice would be discouraged.
711.2(a) (1)
NFPA 101, 2000. 18.2.1

Based on record review and interview, it was determined that the facility did not ensure that fire drills were conducted once per shift per quarter in accordance with NFPA 101. In that no night drills were conducted in the first and second quarter and no evening drills were conducted in the fourth quarter.

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The Finding is:

During the annual survey on 12/29/10, fire drill records were reviewed. It was determined that of all the drills conducted within the first and the second quarters none was conducted on the night shift as reflected in the facility's schedule of drills conducted on the 12am to 8a.m. shift. During the second and fourth quarter no drills were conducted on the 4pm to 12 pm shift.

DATEnone TIMEnone SHIFTnone
Dec. 12:40 p.m. Day
Jan 11:04 am Day No night Drills
Feb 4:08 am Evening
none Mar. 3:20 p.m. Day
Apr. No Night and Evening Drills
May. 10:20 am Day
none Jun. 1:00 a.m. Night
Jul. 10:30 a.m Day
Aug 6:02 p.m. Evening
none Sep. 4:10 am Night
Oct. 9:58 am Day No Evening Drills
Nov. 10:08 a.m . Day
none

In an interview with the Facility's Manager on 12/29/10 at approximately 3:15 p.m., he stated that fire drills are taken very seriously and all fire drills in the future will be conducted once per shift per quarter as per the code requirement.

2000 NFPA 101 - 19.7.1.2
711.2(a) (1)

REPEAT DEFFICIENCY
Based on observations and interviews it was determined that the East side stairway was enclosed with construction having a fire resistance rating of at least one hour. This was evidenced by stairway enclosure doors on the 4th and 3rd floor stairway landing not positively latching.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings are;
During the annual life safety code survey conducted on 12/29/10, it was noted that the East side stairway enclosure doors on the 3rd and the 4th floors were equipped with self closures but when engaged did not positively latch within their frames.
In an interview with the Director of Facility's Management at approximately 3:00 pm on 12/29/10, he stated that the doors would be repaired as soon as possible.
The same issue was cited in the previous standard survey conducted on 12/29/09, the facility's plan of Correction indicated that the issue would have been corrected by 1/5/10, however as the issue continued to exist as of 12/29/10.
711.2(a) (1)
NFPA 101, 2000 19.3.11