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The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following are examples of what was observed:
The following corridor doors were observed with louvers in them:
1. The Administrative Assistant's Office
2. The Medical Director's Office

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2000 NFPA 101, 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 13/4-in. (4.4-cm) 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. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

Unsealed penetrations around a red wire, in the Smoke Barrier by Patient Room 322.
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2000 NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to maintain the exit access per code. Findings include:

During the survey, the following are examples of what was observed:

I. The following doors per interview and observation were observed with either deadbolts that only worked from the outside by staff or hasps with padlocks:
Second Floor
1. The Business Office Storage Closet between rooms 9 and 11.
2. The closet between rooms 5 and 7.
3. The Outpatient Staff Room's inner door.
Third Floor
4. The Residential Classroom Closet.
5. The Adolescent Therapist's Storage Closet between rooms 302 and 304.
6. The Storage Room in the Therapist's Office.

II. The Custodian's Closet between rooms 202 and 204 was more than 7" into the corridor when fully open.
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2000 NFPA 101,19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
2000 NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open. Doors shall not open directly onto a stair without a landing. The landing shall have a width not less than the width of the door. (See 7.2.1.3.)
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The facility failed to maintain the corridor openings per code. Findings include:

During the survey, the following are examples of what was observed:
The following corridor doors were observed with louvers in them:
1. The Administrative Assistant's Office
2. The Medical Director's Office

___________________________
2000 NFPA 101, 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 13/4-in. (4.4-cm) 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. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
.

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

Unsealed penetrations around a red wire, in the Smoke Barrier by Patient Room 322.
____________________________
2000 NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to maintain the exit access per code. Findings include:

During the survey, the following are examples of what was observed:

I. The following doors per interview and observation were observed with either deadbolts that only worked from the outside by staff or hasps with padlocks:
Second Floor
1. The Business Office Storage Closet between rooms 9 and 11.
2. The closet between rooms 5 and 7.
3. The Outpatient Staff Room's inner door.
Third Floor
4. The Residential Classroom Closet.
5. The Adolescent Therapist's Storage Closet between rooms 302 and 304.
6. The Storage Room in the Therapist's Office.

II. The Custodian's Closet between rooms 202 and 204 was more than 7" into the corridor when fully open.
________________________
2000 NFPA 101,19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
2000 NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open. Doors shall not open directly onto a stair without a landing. The landing shall have a width not less than the width of the door. (See 7.2.1.3.)
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