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Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On January 2, 2014 the surveyor, accompanied by the Director of Maintenance, and Plant Operations observed that the following corridor doors would not tightly close when tested.

1. Kitchen, storage/chemical/mop room, door will not close and positively latch, door closing device remover
2. Mechanical room, second floor of supply, door closing device removed
3. Radiology room, B-3, door wedged open and no closing device


During the exit conference on January 2, 2014, the above findings were again acknowledged by the Administrator, COO, director of Maintenance and the Plant Operations Director.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.