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Based on observation the facility failed to assure that the smoke compartmentation between the egress corridor and rooms, adjacent to the egress corridor, were not compromised as per (National Fire Protection Association) NFPA 101 (Life Safety Code) for 2 of 5 floors.

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 February 2, 2015 between February 4, 2015., the following area was observed to be open to the corridor without being separated from the corridor by a smoke resistive partition. Areas maybe open to the corridor, if the area meets the at least one of the exceptions allowed by this code. The first floor radiology waiting area and fifth floor computer charting area is open to the main hall and does not have smoke detectors in it.

Based on observation the facility failed to provide doors that close, latch, or resist the passage of smoke for 8 of 8 patient treatment room doors in the facility as per NFPA 101 (Life Safety Code).

Note: NFPA 101, 2000 edition
NFPA 101 Chapter 18, "New Health Care Occupancy, " 18.3.6.3.1 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 the dates of Febuary 2, 2015 through Febuary 4,2015, the doors of the emergeny treatment rooms do not latch..

Based on observation the facility failed to provide stair enclosures that comply with NFPA 101 (Life Safety Code) for 6 of 12 stair enclosures. The smoke proof enclosure that extends from the end to the West stairway to the outside is not properly protected. This deficiency could affect all 98 patients in the facility.

NFPA 101:19.2.2 Means of Egress Components
19.2.2.3,19.2.2.4 Smokeproof enclosures complying with 7.2 shall be permitted.

7.2 Where an occupancy load is 100 or more doors shall be equipped with panic hardware

Findings:

During a tour of the facility conducted from February 2 through February 4, 2015, observation revealed that the doors at stair C floor 2, stair D floors 1-5, stair E 1-5, stair F floors 1-5, stair G 1st and 5th floor, and stair H 3rd and 4th floors are equipped with round door knobs.

Based on observation and review of documentation, the facility failed to provide a current sprinkler inspection as per NFPA 101:19.7.6 and NFPA 25 for 1 of 1 system. This deficiency affects all 15 patients in the facility.

Findings:

An observation was made on February 4,2015 of the sprinkler system that is located in the mechanical room and the last sprinkler report. Review of the last annual inspection report August 23,2015 reviled that the facility failed to have a current annual inspection done for the sprinkler system. Interview with the administrator revealed that the sprinkler had not been inspected within the last twelve months. Interview with the administrator during the survey process and at the exit interview verified that no additional documentation of a current sprinkler system inspection was available.

Based on observation the facility failed to assure that the smoke compartmentation between the egress corridor and rooms, adjacent to the egress corridor, were not compromised as per (National Fire Protection Association) NFPA 101 (Life Safety Code) for 2 of 5 floors.

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 February 2, 2015 between February 4, 2015., the following area was observed to be open to the corridor without being separated from the corridor by a smoke resistive partition. Areas maybe open to the corridor, if the area meets the at least one of the exceptions allowed by this code. The first floor radiology waiting area and fifth floor computer charting area is open to the main hall and does not have smoke detectors in it.

Based on observation the facility failed to provide doors that close, latch, or resist the passage of smoke for 8 of 8 patient treatment room doors in the facility as per NFPA 101 (Life Safety Code).

Note: NFPA 101, 2000 edition
NFPA 101 Chapter 18, "New Health Care Occupancy, " 18.3.6.3.1 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 the dates of Febuary 2, 2015 through Febuary 4,2015, the doors of the emergeny treatment rooms do not latch..

Based on observation the facility failed to provide stair enclosures that comply with NFPA 101 (Life Safety Code) for 6 of 12 stair enclosures. The smoke proof enclosure that extends from the end to the West stairway to the outside is not properly protected. This deficiency could affect all 98 patients in the facility.

NFPA 101:19.2.2 Means of Egress Components
19.2.2.3,19.2.2.4 Smokeproof enclosures complying with 7.2 shall be permitted.

7.2 Where an occupancy load is 100 or more doors shall be equipped with panic hardware

Findings:

During a tour of the facility conducted from February 2 through February 4, 2015, observation revealed that the doors at stair C floor 2, stair D floors 1-5, stair E 1-5, stair F floors 1-5, stair G 1st and 5th floor, and stair H 3rd and 4th floors are equipped with round door knobs.

Based on observation and review of documentation, the facility failed to provide a current sprinkler inspection as per NFPA 101:19.7.6 and NFPA 25 for 1 of 1 system. This deficiency affects all 15 patients in the facility.

Findings:

An observation was made on February 4,2015 of the sprinkler system that is located in the mechanical room and the last sprinkler report. Review of the last annual inspection report August 23,2015 reviled that the facility failed to have a current annual inspection done for the sprinkler system. Interview with the administrator revealed that the sprinkler had not been inspected within the last twelve months. Interview with the administrator during the survey process and at the exit interview verified that no additional documentation of a current sprinkler system inspection was available.