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Based on observations the facility failed to provide the required smoke resistive, positive latching, solid wood corridor doors in accordance to NFPA 101 section 19.3.6.3. This deficient practice has the potential of affecting one (1) of four (4) smoke compartments of the facility.

Findings include:

On 4/21/16 at 10:15 AM, observation revealed doors to Room 127 and Medical Waste Room on South Wing Hall lacked positive latching device. These doors were incapable of resisting the passage of smoke to the main corridor of the facility.

The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. These deficient practices have the potential of affecting one (1) of four (4) smoke compartments of the facility.

Finding include:

On 4/22/16 at 10:15 AM, observation revealed the smoke barrier wall near Room 127 and Room 104 had a open penetration passing through wall.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observation and testing, the facility failed to provide readily accessible exit discharge as per NFPA 101 19.2.1, NFPA 101 chapter 7.7.1, 7.1.6.4, 7.1.10.1.and all states letter Ref: S&C -07-05. The deficient practice affected one (1) of six (6) exits and all 7 residents in the facility on the day of survey.

Findings Include:

On 4-22-16 at 11:00 AM, observation revealed the fire exit doors on South Wing (leading to the nursing home) did not open and were not accessible during the fire alarm drill and sprinkler system testing.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview on 4-22-16.

7.7.1*

Exits shall terminate directly at a public way or at an exterior 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 a safe access to a public way.

Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.