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Based on visual observation the facility failed to provide corridor doors that were not closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room ' s occupants. The deficient practice had the potential to affect 16 of 16 residents.
2 of 2 corridors had doors that were deficient, 8 out of 10 doors are deficient.

Findings:

During the facility tour, between the hours of 11:00 AM and 4:00 PM on 2/17/16, it was observed that patient doors numbered 105, 108 and 109 do not positive latch in the closed position. It was also observed that patient doors numbered 101,102, 104, 106 and 110 did not create a seal when closed to prevent the passage of smoke.

Interview with administrator revealed the facility was not aware of the door to Rooms 105,108 and 109 was not latching in the frame and door to Rooms 101,102,104, 106 and 110 did not create a seal, when closed, to prevent the transfer of smoke..

Based on visual observation the facility failed to provide exit lighting along the entire length of the exit access. Exit lights provide visual assurance of the direction of the exit door. The deficient practice had the potential to affect 16 of 16 residents.
1 of 8 exit lights are deficient.

Findings:

During the facility tour, between the hours of 11:00 AM and 4:00 PM on 2/17/16, it was observed that one directional exit sign was not working.

Interview with administrator revealed the facility was not aware that one exit sign was not working.

Based on visual observation, the facility failed to maintain the space between the penetrating item and the smoke barrier was filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 16 of 16 residents.
1 of 1 smoke barriers were deficient.

Findings:

During the facility tour, between the hours of 11:00 AM and 4:00 PM on 2/17/16, it was observed that the smoke barrier had unsealed penetrations.

Interview with administrator revealed the facility was not aware that the smoke barrier had a penetrations that were not sealed.

Based on visual observation the facility failed to provide corridor doors that were not closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room ' s occupants. The deficient practice had the potential to affect 16 of 16 residents.
2 of 2 corridors had doors that were deficient, 8 out of 10 doors are deficient.

Findings:

During the facility tour, between the hours of 11:00 AM and 4:00 PM on 2/17/16, it was observed that patient doors numbered 105, 108 and 109 do not positive latch in the closed position. It was also observed that patient doors numbered 101,102, 104, 106 and 110 did not create a seal when closed to prevent the passage of smoke.

Interview with administrator revealed the facility was not aware of the door to Rooms 105,108 and 109 was not latching in the frame and door to Rooms 101,102,104, 106 and 110 did not create a seal, when closed, to prevent the transfer of smoke..

Based on visual observation the facility failed to provide exit lighting along the entire length of the exit access. Exit lights provide visual assurance of the direction of the exit door. The deficient practice had the potential to affect 16 of 16 residents.
1 of 8 exit lights are deficient.

Findings:

During the facility tour, between the hours of 11:00 AM and 4:00 PM on 2/17/16, it was observed that one directional exit sign was not working.

Interview with administrator revealed the facility was not aware that one exit sign was not working.

Based on visual observation, the facility failed to maintain the space between the penetrating item and the smoke barrier was filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 16 of 16 residents.
1 of 1 smoke barriers were deficient.

Findings:

During the facility tour, between the hours of 11:00 AM and 4:00 PM on 2/17/16, it was observed that the smoke barrier had unsealed penetrations.

Interview with administrator revealed the facility was not aware that the smoke barrier had a penetrations that were not sealed.