17 Fire Code Deficiencies at Arbour HRI included Obstructed Fire Sprinklers and Doors that Did not Latch

Arbour Human Resource Institute (Arbour HRI) in Brookline, Massachusetts was cited by the Centers for Medicare and Medicaid Services (CMS) for deficiencies related to life safety codes. CMS  found that the facility’s sprinkler system did not meet fire safety codes. CMS found five areas in the facility that had no sprinkler protection at all, as well as sprinkler heads obstructed by paint and inappropriately spaced sprinkler heads in a nurses’ station, a medication room, and a day room. Arbour HRI failed to provide documentation that it performed inspections of the sprinkler system’s main alarm valve and pressure gauges. CMS also found doors that did not latch properly, including hallway doors to four patient rooms and the door to the women’s locker room on the main level. In addition, CMS found that the facility’s main stairwell did not have an approved fire safety door from the 1st to 2nd floor and had no door at all between the 2nd and 3rd floors. Also, the boiler room in the basement was not separated by an approved 1-hour rated fire door. To address this issue the facility agreed to install fire safety doors, but did not plan to have them until 5/16/2014, almost 3 months after the inspection. CMS found additional violations of life safety codes including the following:
  • The facility’s emergency lighting was not operational on any of the 4 levels of the building.
  • There was snow obstructing emergency exit doors, but it had not snowed for 9 days.
  • Two stairwell landings were used for storage with one area full of ceiling tiles, carpet, and sheet plastic without a proper fire resistant enclosure.
  • The facility failed to conduct fire drills as required.
  • The facility had exposed electrical wiring in a bathroom, patient meetings rooms, and the patient phone room.
To address these deficiencies, the facility agreed to make plans for repairs and perform quarterly rounds to review deficiencies.