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Based on observation the facility failed to provide doors that did not close, latch, or resist the passage of smoke for 5 of 31 doors in the facility as per NFPA 101 (Life Safety Code). This deficiency could affect 14 residents 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 tour of the facility on April 9, 2012 between 2:00 p.m. and 4:00 p.m., the door to rooms 102, 106, 108, 110, and DON office have gaps between the door and frame. If the doors do not close completely than the doors will not resist the passage of smoke.

Based on observation, the facility failed to provide exit signage that is in accordance with the National Fire Protection Association-NFPA 101 (Life Safety Code) for 2 of 4 exit signs. Exit signs shall indicate the direction of travel and shall be illuminated as to be legible in both normal and emergency lighting conditions. This deficiency affects all 14patients in the facilities.

Actual Code: NFPA 101, 2000 edition
NFPA 101:7.10.2 (Directional Signs)
7.10.2 A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
Or
NFPA 101:7.10.5. (Illumination of signs)
7.10.5.1 Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

Findings:

During facility tour on April 9, 2012 between 2:00 p.m. and 4:00 p.m., the facility failed to provide exit signage that shows the direction of travel to reach the nearest exit. There are 2 of 6 areas that do not show the nearest exit.

The following areas do not have exit signs.
1. There is no exit sign from the east hall showing the nearest exit on the main hall.
2. There is no exit sign from the main hall showing the exit in the Multi-purpose room.

Based on observation the facility failed to provide doors that did not close, latch, or resist the passage of smoke for 5 of 31 doors in the facility as per NFPA 101 (Life Safety Code). This deficiency could affect 14 residents 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 tour of the facility on April 9, 2012 between 2:00 p.m. and 4:00 p.m., the door to rooms 102, 106, 108, 110, and DON office have gaps between the door and frame. If the doors do not close completely than the doors will not resist the passage of smoke.

Based on observation, the facility failed to provide exit signage that is in accordance with the National Fire Protection Association-NFPA 101 (Life Safety Code) for 2 of 4 exit signs. Exit signs shall indicate the direction of travel and shall be illuminated as to be legible in both normal and emergency lighting conditions. This deficiency affects all 14patients in the facilities.

Actual Code: NFPA 101, 2000 edition
NFPA 101:7.10.2 (Directional Signs)
7.10.2 A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
Or
NFPA 101:7.10.5. (Illumination of signs)
7.10.5.1 Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

Findings:

During facility tour on April 9, 2012 between 2:00 p.m. and 4:00 p.m., the facility failed to provide exit signage that shows the direction of travel to reach the nearest exit. There are 2 of 6 areas that do not show the nearest exit.

The following areas do not have exit signs.
1. There is no exit sign from the east hall showing the nearest exit on the main hall.
2. There is no exit sign from the main hall showing the exit in the Multi-purpose room.