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Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas within a supervised sprinklered facility are required to be constructed to resist the passage of smoke and provide a door that self closes and self-latches properly. The deficient practice had the potential to affect zero of twenty eight patients.

Findings:

During the facility tour on April 6, 2023 between the hours of 8:00 a.m. to 11:30 a.m. the maintenance room and the storage room located across from the maintenance room lacked a self-closing device. The maintenance room had a louver in the wall; thus, the room was not smoke tight.

The interview with the Facility Manager revealed the facility was not aware that the doors to the hazardous areas were required to self-close and self-latch in the frame. The Facility Manager was also unaware the maintenance room was required to be smoke tight; thus, a louver in the interior wall was not acceptable.

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 nine of twenty eight residents.
There was three of four corridors that had resident sleeping room corridor doors that were deficient.
Findings:

During the facility tour on April 6, 2023 between the hours of 8:00 a.m. to 11:30 a.m. the patient rooms identified as S2, S3, S4, L101, L102, L107, L109, S16, S23 lacked properly functioning self-latching door hardware.


The interview with the Facility Maintenance Manager revealed the facility was aware of the non-latching patient corridor doors and is awaiting the arrival of the properly functioning hardware to be delivered to the facility for installation of patient corridor doors.