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Based on observation the facility failed to provide corridors that are separate from all other areas as per (National Fire Protection Association) NFPA 101 (Life Safety Code) for 1 of 7 corridors on the first floor. This deficiency affects any patients using the radiology department of the facility.

Note: NFPA 101, 2000 Edition:

NFPA 101, Chapter 19, "Corridor" 19.3.6.1, Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5.

Findings:

During a tour of the facility July 10, 2012 between 9:00 a.m. and 2:30 p.m., the following area was observed to be open to the corridor without being separated from the corridor by a smoke resistive partition. Areas may be open to the corridor, if the area meets the at least one of the exceptions allowed by this code. The radiology reception area is open to the radiology corridor and does not have smoke detectors in it.

Based on observation the facility failed to provide doors that did not close, latch, or resist the passage of smoke for 11 of 350 corridor doors in the facility as per NFPA 101 (Life Safety Code). This deficiency could affect all 33 patients in 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.

Findings:

During facility tour on July 10, 2012 between 9:00 a.m. and 2:30 p.m. the door to the following areas not latching or resisting the passage of smoke.
1. The door to rooms 106, 104, 119, 121, 125, 126, 133, & 130 had gaps between the door and the frame. These gaps would allow smoke to pass between the rooms and the corridor.
2. The door to rooms 112 and 120 did not latch when closed.
3. The cross corridor doors to the ICU suite and not latching.

Based on observation the facility failed to provide complete protection for 3 of 9 hazardous areas in the tower area as per National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency could have the potential to cause harm to all resident around the two nursing station areas 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 July 10, 2012 between 9:00 a.m. and 2:30 p.m., it was observed that the two storage room and the elevator equipment room at the east end of each floor of the patient tower area are not resisting the passage of smoke. There is a gap between the double doors to each room.