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Based on observation the facility failed to provide doors that close, latch, or resist the passage of smoke for 4 of 9 departments on the first floor. This deficiency affects all the patients in these areas of the facility.

Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, " Existing Health Care Occupancy, " 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4-in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required.
And
Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, "Existing Health Care Occupancy, " 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted. Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Findings:

During facility tour on April 17, 2012 between 9:00 a.m. and 2:30 p.m. the door to the following rooms did not close, latch, or resist the passage of smoke.

1. The corridor door to the medical record office is not latching.
2. The corridor door to the laboratory area is not latching.
3. The two sets of corridor door to cafeteria dining room are not latching.
4. The gift shop corridor door is not latching.

Based on observation the facility failed to provide proper protection to all hazardous areas as per NFPA 101 (Life Safety Code). This deficiency affects any patients in this area of the facility.

Note: NFPA 101, 2000 Edition:
NFPA 101, Chapter 3, "Protection" 19.3.5.4 if the hazardous areas is sprinkled then the walls and doors to the hazardous area shall be smoke resistive and the door shall be self-closing.

Findings:

During a tour of the facility on April 17, 2012 between 9:00 a.m. and 2:30 p.m., it was observed that the back door to the central supply room is does not latch. This door does not have a latching device.

Based on observation, the facility failed to provide proper sprinkler coverage to all parts of the building as per NFPA 101 (Life Safety Code) and NFPA 13 (Standard for the Installation of Sprinkler System) for 1 of 4 floors. This deficiency could affect all 20 residents on the second floor.

Note: NFPA 13, 1999 Edition:

NFPA 13, Chapter 5, "Installation Requirements " 5-3.1.5.2 when existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.

Findings:

During a tour of the facility on April 17, 2012 between 9:00 a.m. and 2:30 p.m., it was observed that the facility has both standard-response and quick-response sprinkler heads on the second floor. There are both standard-response and quick-response sprinkler heads in the corridor of second floor north side. The quick-response sprinkler head could prevent the standard-response heads from working properly during a fire

Based on observation the facility failed to provide doors that close, latch, or resist the passage of smoke for 4 of 9 departments on the first floor. This deficiency affects all the patients in these areas of the facility.

Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, " Existing Health Care Occupancy, " 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4-in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required.
And
Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, "Existing Health Care Occupancy, " 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted. Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Findings:

During facility tour on April 17, 2012 between 9:00 a.m. and 2:30 p.m. the door to the following rooms did not close, latch, or resist the passage of smoke.

1. The corridor door to the medical record office is not latching.
2. The corridor door to the laboratory area is not latching.
3. The two sets of corridor door to cafeteria dining room are not latching.
4. The gift shop corridor door is not latching.

Based on observation the facility failed to provide proper protection to all hazardous areas as per NFPA 101 (Life Safety Code). This deficiency affects any patients in this area of the facility.

Note: NFPA 101, 2000 Edition:
NFPA 101, Chapter 3, "Protection" 19.3.5.4 if the hazardous areas is sprinkled then the walls and doors to the hazardous area shall be smoke resistive and the door shall be self-closing.

Findings:

During a tour of the facility on April 17, 2012 between 9:00 a.m. and 2:30 p.m., it was observed that the back door to the central supply room is does not latch. This door does not have a latching device.

Based on observation, the facility failed to provide proper sprinkler coverage to all parts of the building as per NFPA 101 (Life Safety Code) and NFPA 13 (Standard for the Installation of Sprinkler System) for 1 of 4 floors. This deficiency could affect all 20 residents on the second floor.

Note: NFPA 13, 1999 Edition:

NFPA 13, Chapter 5, "Installation Requirements " 5-3.1.5.2 when existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.

Findings:

During a tour of the facility on April 17, 2012 between 9:00 a.m. and 2:30 p.m., it was observed that the facility has both standard-response and quick-response sprinkler heads on the second floor. There are both standard-response and quick-response sprinkler heads in the corridor of second floor north side. The quick-response sprinkler head could prevent the standard-response heads from working properly during a fire