EVENGLOW LODGE
Facility I.D. Number 0008425
215 E. Washington
Pontiac, IL 61764
Date of Survey: 01/03/01
Notice of Violation: 03/19/01
Special Licensure Survey
All necessary precautions shall be taken to assure that the residents' environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
Maintain the building in good repair, safe and free of the following: cracks in floors, walls or ceilings, peeling wallpaper or paint, warped or loose boards; warped, broken, loose or cracked floor covering such as tile or linoleum, loose handrails or railings, loose or broken window panes and any other similar hazards.
The 1981 Edition of the National Fire Protection Association (NFPA) Standard No. 101, Life Safety Code for existing structures and all appropriate references under Appendix "B" of that Code, but no subsequently amended edition of the Code, shall apply to and become a part of these standards. Pursuant to the Medicare/Medicaid certification requirements of 42 CFR 405.1134(a) (1983) and 42 CFR 442.321(c) (1983), but no subsequently amended editions of these Federal regulations, any skilled nursing facility that on December 4, 1980, or on November 26, 1982, or any intermediate care facility that on November 26, 1982, complied with the requirements of the 1967 or 1973 edition of the Life Safety Code, rather than the 1981 edition of the Life Safety Code, will be accepted by the Department for licensure and certification as long as the facility continues to remain in compliance with the 1967 or 1973 edition of the Code.
Life Safety Code 13-2.1 Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 5.
5- 5.1.1 Exits shall be so located and exit access shall be so arranged that exits are readily accessible at all times.
5-7.1 All exits shall terminate directly at a public way or at an exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with safe access to a public way.
13-2.3.3 Any required aisle, corridor, or ramp shall be not less than 48 inches in clear width when serving as means of egress from patient sleeping rooms.
31-1.2.1 Every required exit, exit access or exit discharge shall be continuously maintained free of obstructions or impediments to full instant use in the case of fire or other emergency.
Based on observations made on 1/2/01, staff interviews and consultation with IDPH Regional Office staff and Life Safety Code field staff, it was determined that the facility failed to ensure that the building was maintained to protect the health and safety of residents, personnel and the public. The facility failed to ensure that designated fire exit landings were clear of drifted snow for three of five exits on the first floor of the health center.
The findings include:
1. On 1/2/01at approximately 12:30 p.m., it was observed that the exit landing for the west first floor resident wing was drifted with snow that was approximately one and a half feet deep. At 1:00 p.m., the surveyor attempted to open the west exit from the inside. The door was able to be opened approximately two feet before being blocked by a drift. This exit opens onto a six foot landing that is five feet wide and approximately a foot and a half above grade. This landing was drifted with approximately one to two feet of soft snow. At the end of the landing were three steps that lead to the sidewalk. These were drifted with 6''-12" of snow. From the exit door to the sidewalk is approximately 10 feet.
The fire exit door at the end of the first floor east wing was also drifted with approximately two feet of snow. The landing was approximately six feet by five feet wide and was approximately two feet above grade. There were four steps leading from the end of the landing to the sidewalk. The sidewalk was approximately 10-12 feet from the exit door.
The Health Center residents all reside on the east and west wings on the first and second floor. The snow blocked exits serve as the means of emergency egress for both floors at the east and west ends. On 1/2/01, there were 36 residents residing on the first floor and 34 residents residing on the second floor.
There are residents in the facility that are totally dependant on staff for ambulation; residents who are wheelchair bound and residents who use a variety of ambulation aids such as canes and walkers who would be unable to gain emergency egress from these east and west exit doors due to the snow accumulation.
2. On 1/2/01, at approximately 12:00 noon the surveyor noticed that the outside fenced courtyard beside the first floor dining room was drifted with snow. There was a lighted exit sign above the dining room door to the courtyard. There was approximately four inches of snow on the ground along the window side of the dining room and a drift at the gate that was approximately one foot deep. Beyond the sidewalk area the snow was drifted approximately one to two feet in the yard. The exit door could be opened, however the sidewalk and gate area needed to be cleared to allow egress to the cleared sidewalk that leads to the street. The sidewalk was about thirty five feet along the building to the gate. From the gate it was another approximate 10 feet to the cleared sidewalk.
3. At 1:00 p.m., the surveyors notified the Director of Nursing (E1) that the designated fire exits for the east and west wings and the courtyard were drifted with snow and needed to be cleared to a public way. The sidewalks were clear to the streets on all sides of the building.
4. At 2:10 p.m., the surveyor observed that the east and west exits were clear to the sidewalks and had been salted. The courtyard exit had not yet been shoveled.
5. At 2:30 p.m., the surveyor interviewed E2 on the elevator. E2 stated that he was one of the staff responsible for snow removal. E2 stated that they had last shoveled snow on Saturday (12/30/00) following a significant snow accumulation on Friday evening (12/29/00). E2 stated that they normally shovel the side walks around the perimeter of the building, the Memorial Building (Shelter Care) main entrance and circle drive, the Health Center main entrance (North ), the funeral door located off the walk way to the east of the first floor dining room and they clear from the Memorial Building to the parking lot. The surveyor asked E2 about the two exit landings on the east and west wings of the first floor Health Center. E2 stated that they don't usually shovel those areas because no one goes out that way. E2 stated "I haven't shoveled those exits since I've been here." E2 also stated that they don't shovel the courtyard exit.