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Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting 5 patients and all occupants in 1 of 4 smoke zones. This facility has a capacity of 21 and a census of 5 patients.

Findings Include:

During the tour conducted on 1/6/2014 between 8:00 A.M. and 1:00 P.M. the following is observed:

1.) At approximately 10:20 A.M. it is discovered that the door leading to the exit corridor does not latch in patient Room 112.

The Maintenance Director was present and acknowledged the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all 21 patients and occupants in 4 of 4 smoke zones. This facility has a capacity of 21 and a census of 5 patients.

Findings Include:

During the tour conducted on 1/6/2014 between 8:00 A.M. and 1:00 P.M. the following is observed:

1.) At approximately 9:35 A.M. it is discovered that the most recent annual sprinkler inspection was performed on 12/18/2012.

The Maintenance Director was present and acknowledged the finding.

NFPA Standard: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2000 NFPA 101, 9.7.5.

Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting 5 patients and all occupants in 1 of 4 smoke zones. This facility has a capacity of 21 and a census of 5 patients.

Findings Include:

During the tour conducted on 1/6/2014 between 8:00 A.M. and 1:00 P.M. the following is observed:

1.) At approximately 10:20 A.M. it is discovered that the door leading to the exit corridor does not latch in patient Room 112.

The Maintenance Director was present and acknowledged the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all 21 patients and occupants in 4 of 4 smoke zones. This facility has a capacity of 21 and a census of 5 patients.

Findings Include:

During the tour conducted on 1/6/2014 between 8:00 A.M. and 1:00 P.M. the following is observed:

1.) At approximately 9:35 A.M. it is discovered that the most recent annual sprinkler inspection was performed on 12/18/2012.

The Maintenance Director was present and acknowledged the finding.

NFPA Standard: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2000 NFPA 101, 9.7.5.