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Based on observation, the facility failed to ensure safety to patients, staff and visitors of the facility due to lack of astragals in 4 of 4 sets of smoke doors to prevent smoke transfer from one smoke compartment into another. This affected all 5 smoke compartments in the facility.

Findings Include

During a tour of the facility with Staff C (facilities manager) on 6/13/2011, Surveyor 12316 observed between 1:30 pm to 1:40 pm that 4 sets of cross-corridor smoke doors in 4 patient sleeping wings had approximately ? inch gap at the meeting edge and was more than necessary for door operation. The doors did not have astragals, nor beveled to limit the gap to a minimum necessary for door operation. Such a wide gap at the meeting edge does not prevent smoke transfer from one smoke compartment into another in the event of fire, and does not meet NFPA 101 8.3.4.1 and 18.3.7.8.

The above deficiency was acknowledged by the facilities coordinator, and food services supervisor at the time of discovery, and confirmed with Staff E (house keeping manager) at the exit conference on 6/15/2011 at 11 am.

Based on observation and staff interview, the facility failed to ensure safety to patients due to lack of clear access to one of five exits in accordance with NFPA 101 7.1.10. This deficient practice affects 1 of 5 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facilities manager) on 6/14/2011, Surveyor 12316 observed at 9:02 am that there were 1 wheel chair and 1 chair stored in the entry Vestibule 103 blocking access to exterior exit door. Storage of chairs in the vestibule did not provide a free and clear means of egress to the exit.

The above deficiency was acknowledged by the facilities coordinator, and food services supervisor at the time of discovery, and confirmed with Staff E (house keeping manager) at the exit conference on 6/15/2011 at 11 am.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors due to lack of positive latching hardware or other fastening device on 3 corridor doors of the Kitchen in accordance with NFPA 101 7.2.1.5.4. This deficient practice affected the south half of Building E.

Findings include

During a tour of the facility with Staff C (facilities manager), and Staff D (food services supervisor) on 6/14/2011, Surveyor 12316 observed at 9:25 am that three corridor doors of the Kitchen did not have positive latching hardware or other fastening device on doors in accordance with the NFPA 101 7.2.1.5.4 requirement. The doors had dead bolts with thumb latch, which is not acceptable due to more than one releasing operation required to open or close the door. Lack of positive latching on doors may not prevent fire and smoke from propagation in the event of fire.

The above deficiency was acknowledged by the facilities coordinator, and food services supervisor at the time of discovery, and confirmed with Staff E (house keeping manager) at the exit conference on 6/15/2011 at 11 am.

Based on observation, the facility failed to ensure safety to patients, staff and visitors of the facility due to lack of astragals in 4 of 4 sets of smoke doors to prevent smoke transfer from one smoke compartment into another. This affected all 5 smoke compartments in the facility.

Findings Include

During a tour of the facility with Staff C (facilities manager) on 6/13/2011, Surveyor 12316 observed between 1:30 pm to 1:40 pm that 4 sets of cross-corridor smoke doors in 4 patient sleeping wings had approximately ? inch gap at the meeting edge and was more than necessary for door operation. The doors did not have astragals, nor beveled to limit the gap to a minimum necessary for door operation. Such a wide gap at the meeting edge does not prevent smoke transfer from one smoke compartment into another in the event of fire, and does not meet NFPA 101 8.3.4.1 and 18.3.7.8.

The above deficiency was acknowledged by the facilities coordinator, and food services supervisor at the time of discovery, and confirmed with Staff E (house keeping manager) at the exit conference on 6/15/2011 at 11 am.

Based on observation and staff interview, the facility failed to ensure safety to patients due to lack of clear access to one of five exits in accordance with NFPA 101 7.1.10. This deficient practice affects 1 of 5 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff C (facilities manager) on 6/14/2011, Surveyor 12316 observed at 9:02 am that there were 1 wheel chair and 1 chair stored in the entry Vestibule 103 blocking access to exterior exit door. Storage of chairs in the vestibule did not provide a free and clear means of egress to the exit.

The above deficiency was acknowledged by the facilities coordinator, and food services supervisor at the time of discovery, and confirmed with Staff E (house keeping manager) at the exit conference on 6/15/2011 at 11 am.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors due to lack of positive latching hardware or other fastening device on 3 corridor doors of the Kitchen in accordance with NFPA 101 7.2.1.5.4. This deficient practice affected the south half of Building E.

Findings include

During a tour of the facility with Staff C (facilities manager), and Staff D (food services supervisor) on 6/14/2011, Surveyor 12316 observed at 9:25 am that three corridor doors of the Kitchen did not have positive latching hardware or other fastening device on doors in accordance with the NFPA 101 7.2.1.5.4 requirement. The doors had dead bolts with thumb latch, which is not acceptable due to more than one releasing operation required to open or close the door. Lack of positive latching on doors may not prevent fire and smoke from propagation in the event of fire.

The above deficiency was acknowledged by the facilities coordinator, and food services supervisor at the time of discovery, and confirmed with Staff E (house keeping manager) at the exit conference on 6/15/2011 at 11 am.