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Based on interview and record review the facility failed to provide documentation of flame spread ratings for one interior stairwell finish.

Findings include:
Review of the facility's interior finish records and interview with Staff A (Maintenance Director) during tour on 12/18/13 at approximately 1:00 p.m. it was observed that in the stairwell #5 there are 25 square carpet panels (approximately 24 inch's by 24 inch's) mounted on the walls throughout the stairwell enclosure and Staff A cannot provide any documentation of the Flame Spread Resistance Rating for interior means of egress carpet panel finish's.

Interview with Staff A during the exit conference confirmed that the installation and flame resistance record's could not be located.

Based on observations during tour the facility failed to ensure that 2 doors could resist the passage of smoke and that roller latches are not being used.

Findings include:
Observation during tour of the facility on 12/18/13 with Staff A (Maintenance Director) between 2:00 p.m. and 3:00 p.m. it was revealed that the following 2 doors had gaps larger than the maximum 1/2" allowed and the following 2 doors have roller latches being used which are not allowed in health care facility's.
1. The 2nd floor Court Visitors Room door has a gap larger than 3/4".
2. The 2nd floor Rehab room door has a gap larger than 1".

1. The 2nd floor Rehab room door has a roller latch in use.
2. The 2nd floor door #200 has a roller latch in use.

Interview with Staff A at the time of observation confirmed the findings.

7.2.4.3.1 NFPA 101, LIFE SAFETY CODE
Fire Barriers separating building areas between which there are Horizontal Exits shall have a 2 hour fire resistance rating and shall provide a separation that is continuous to the ground.(see also 8.2.3)

8.2.3.2.1 NFPA, 101 LIFE SAFETY CODE
Door assemblies in fire barriers shall be of an approved type with the appropriate fire rating for the location in which they are installed and shall comply with the following:
(a) Fire doors shall be installed in accordance with NFPA 80 STANDARD FOR FIRE DOORS AND FIRE WINDOWS

2-1.4.1 NFPA 80 STANDARD FOR FIRE DOORS AND FIRE WINDOWS
Self-closing doors shall swing easily and freely and shall be equipped with a closing device to cause the door to close and latch each time it is opened.

Based on observation during tour, the facility failed to ensure that 1 set of fire doors have fire rated hardware installed.

Findings include:
Observation during tour on 12/18/13 with Staff A (Maintenance Director) at approximately 1:00 p.m. revealed that the Fire Barrier Doors located in the basement, outside of the Occupational Health Services office do not have Fire Rated hardware installed capable of latching the doors in the closed position.

Interview with Staff A during the exit conference confirmed that the one set of fire doors do not have fire rated hardware installed.

7.2.1.4.4 NFPA 101 LIFE SAFETY CODE
Screen Door Assemblies and Storm Door Assemblies:
Screen and storm door assemblies used in the means of egress shall be subject to the requirements for direction of swing that are apical to other door assembles used in the means of egress.

7.2.1.4.2 NFPA 101 LIFE SAFETY CODE
Doors shall swing in the direction of egress travel where used in an exit enclosure or where serving a high hazard contents area,unless it is a door from an individual living unit that opens directly into an exit enclosure.

Based on observation the facility failed to ensure that the kitchen screen door swings with egress travel.

Findings include:
Observations during the tour on 12/19/13 with Staff A (Maintenance Director) at 10:30 a.m. it was revealed that the facility's kitchen area has an exit discharge door to the parking lot with a screen door on the inside that does not swing with the direction of egress travel.

Interview with Staff A at the time of observation confirmed the findings.

Based on interview and record review the facility failed to provide documentation of flame spread ratings for one interior stairwell finish.

Findings include:
Review of the facility's interior finish records and interview with Staff A (Maintenance Director) during tour on 12/18/13 at approximately 1:00 p.m. it was observed that in the stairwell #5 there are 25 square carpet panels (approximately 24 inch's by 24 inch's) mounted on the walls throughout the stairwell enclosure and Staff A cannot provide any documentation of the Flame Spread Resistance Rating for interior means of egress carpet panel finish's.

Interview with Staff A during the exit conference confirmed that the installation and flame resistance record's could not be located.

Based on observations during tour the facility failed to ensure that 2 doors could resist the passage of smoke and that roller latches are not being used.

Findings include:
Observation during tour of the facility on 12/18/13 with Staff A (Maintenance Director) between 2:00 p.m. and 3:00 p.m. it was revealed that the following 2 doors had gaps larger than the maximum 1/2" allowed and the following 2 doors have roller latches being used which are not allowed in health care facility's.
1. The 2nd floor Court Visitors Room door has a gap larger than 3/4".
2. The 2nd floor Rehab room door has a gap larger than 1".

1. The 2nd floor Rehab room door has a roller latch in use.
2. The 2nd floor door #200 has a roller latch in use.

Interview with Staff A at the time of observation confirmed the findings.

7.2.4.3.1 NFPA 101, LIFE SAFETY CODE
Fire Barriers separating building areas between which there are Horizontal Exits shall have a 2 hour fire resistance rating and shall provide a separation that is continuous to the ground.(see also 8.2.3)

8.2.3.2.1 NFPA, 101 LIFE SAFETY CODE
Door assemblies in fire barriers shall be of an approved type with the appropriate fire rating for the location in which they are installed and shall comply with the following:
(a) Fire doors shall be installed in accordance with NFPA 80 STANDARD FOR FIRE DOORS AND FIRE WINDOWS

2-1.4.1 NFPA 80 STANDARD FOR FIRE DOORS AND FIRE WINDOWS
Self-closing doors shall swing easily and freely and shall be equipped with a closing device to cause the door to close and latch each time it is opened.

Based on observation during tour, the facility failed to ensure that 1 set of fire doors have fire rated hardware installed.

Findings include:
Observation during tour on 12/18/13 with Staff A (Maintenance Director) at approximately 1:00 p.m. revealed that the Fire Barrier Doors located in the basement, outside of the Occupational Health Services office do not have Fire Rated hardware installed capable of latching the doors in the closed position.

Interview with Staff A during the exit conference confirmed that the one set of fire doors do not have fire rated hardware installed.

7.2.1.4.4 NFPA 101 LIFE SAFETY CODE
Screen Door Assemblies and Storm Door Assemblies:
Screen and storm door assemblies used in the means of egress shall be subject to the requirements for direction of swing that are apical to other door assembles used in the means of egress.

7.2.1.4.2 NFPA 101 LIFE SAFETY CODE
Doors shall swing in the direction of egress travel where used in an exit enclosure or where serving a high hazard contents area,unless it is a door from an individual living unit that opens directly into an exit enclosure.

Based on observation the facility failed to ensure that the kitchen screen door swings with egress travel.

Findings include:
Observations during the tour on 12/19/13 with Staff A (Maintenance Director) at 10:30 a.m. it was revealed that the facility's kitchen area has an exit discharge door to the parking lot with a screen door on the inside that does not swing with the direction of egress travel.

Interview with Staff A at the time of observation confirmed the findings.