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Based on observation and staff interview, the facility failed to ensure all smoke barriers were maintained as a continuous membrane in 1 of 5 smoke compartments. The findings were:
Observations on 7/24/13 at 11:48 AM revealed the following concerns:
a. In the Switch room, a 6" ceiling panel was missing. In addition, there was an approximate 4" semicircular hole in the corner of one ceiling tile in the same room.
b. In the nursing storage room, there was noted a hole through which several electrical wires were running. The hole did not have any caulking compound.
c. The maintenance manager verified this finding at the time of the observations.

Reference: NFPA 101, Life Safety Code, 2000 edition.
19.3.6.2.2* Corridor walls and ceilings shall form a barrier to limit the transfer of smoke.

Based on observation and staff interview, the facility failed to ensure all corridor doors were resistant to the passage of smoke in 1 of 5 smoke compartments. The findings were:
Observations on 7/24/13 at 2:48 PM revealed the corridor door to the emergency mop room required significant force greater than 5 foot pounds of pressure to both open and close the door. The maintenance manager verified this finding at the time of the observation.

Reference: NFPA 101, Life Safety Code, 2000 edition,
Section 19.3.6.3.2. Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5lbf is applied at the latch edge of the door.

Based on observation and staff interview, the facility failed to ensure 2 of 4 smoke barrier doors were resistant to the passage of smoke. The findings were:
Observations on 7/24/13 between 9:00 AM and 2:30 PM revealed two cross corridor doors didn't close forming a tight seal. The doors were located at the entry to the 100 pod as well as the door to ER hallway from RN station. The maintenance manager verified this finding at the time of the observations.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Section 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self closing or automatic closing in accordance with 19.2.2.2.6.
8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Based on observation and staff interview, the facility failed to protect hazardous areas in 2 of 4 smoke compartments. The findings were:
Observations on 7/24/13 between 9:00 AM and 2:30 PM revealed the door to the soiled linen in the physical therapy department did have a self closure device (SCD) attached. However, the door did not close upon 3 separate attempts.
In addition, the door to the copy room by the nurse's station also did have a SCD attached. However, the door did not close upon 3 separate attempts as well. The maintenance manager verified these findings at the time of the observations.

Based on observation and staff interview, the facility failed to ensure all smoke barriers were maintained as a continuous membrane in 1 of 5 smoke compartments. The findings were:
Observations on 7/24/13 at 11:48 AM revealed the following concerns:
a. In the Switch room, a 6" ceiling panel was missing. In addition, there was an approximate 4" semicircular hole in the corner of one ceiling tile in the same room.
b. In the nursing storage room, there was noted a hole through which several electrical wires were running. The hole did not have any caulking compound.
c. The maintenance manager verified this finding at the time of the observations.

Reference: NFPA 101, Life Safety Code, 2000 edition.
19.3.6.2.2* Corridor walls and ceilings shall form a barrier to limit the transfer of smoke.

Based on observation and staff interview, the facility failed to ensure all corridor doors were resistant to the passage of smoke in 1 of 5 smoke compartments. The findings were:
Observations on 7/24/13 at 2:48 PM revealed the corridor door to the emergency mop room required significant force greater than 5 foot pounds of pressure to both open and close the door. The maintenance manager verified this finding at the time of the observation.

Reference: NFPA 101, Life Safety Code, 2000 edition,
Section 19.3.6.3.2. Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5lbf is applied at the latch edge of the door.

Based on observation and staff interview, the facility failed to ensure 2 of 4 smoke barrier doors were resistant to the passage of smoke. The findings were:
Observations on 7/24/13 between 9:00 AM and 2:30 PM revealed two cross corridor doors didn't close forming a tight seal. The doors were located at the entry to the 100 pod as well as the door to ER hallway from RN station. The maintenance manager verified this finding at the time of the observations.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Section 19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self closing or automatic closing in accordance with 19.2.2.2.6.
8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Based on observation and staff interview, the facility failed to protect hazardous areas in 2 of 4 smoke compartments. The findings were:
Observations on 7/24/13 between 9:00 AM and 2:30 PM revealed the door to the soiled linen in the physical therapy department did have a self closure device (SCD) attached. However, the door did not close upon 3 separate attempts.
In addition, the door to the copy room by the nurse's station also did have a SCD attached. However, the door did not close upon 3 separate attempts as well. The maintenance manager verified these findings at the time of the observations.