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Based on observation the facility failed to provide doors that did not close, latch, or resist the passage of smoke for 7 of 110 in the facility as per NFPA 101 ( Life Safety Code). This deficiency affects all 27 patients in the facility.

Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, " Existing Health Care Occupancy, " 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 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 facility tour on February 1, 2011 between 12:30 p.m. and 4:00 p.m. the door to rooms 106, 110, 113, 114, 203, 206, 214 have gaps between the frame and the door. The door to these rooms were latching but was not resisting the passage of smoke.

Based on observation, the facility failed to provide exit signage that are in accordance with the National Fire Protection Association-NFPA 101 (Life Safety Code) for 3 of 18 exit signs. Exit signs shall indicate the direction of travel and shall be illuminated as to be legible in both normal and emergency lighting conditions. This deficiency affects the 27 residents on the Recovery unit.

Actual Code: NFPA 101, 2000 edition
NFPA 101:7.10.2 (Directional Signs)
7.10.2 A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
or
NFPA 101:7.10.5. (Illumination of signs)
7.10.5.1 Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

Findings:

During facility tour on February 1, 2011 between 12:30 p.m. and 3:00 p.m., the facility failed to provide exit signage that are lighted completely.

The following exit signs had bulbs that were not lit.
1. The exit sign by room 207 had a burnt bulb.
2. The exit sign by room 204 had a burnt bulb.
3. The exit sign by room 200 had a burnt bulb.

Based on observation the facility failed to provide doors that did not close, latch, or resist the passage of smoke for 7 of 110 in the facility as per NFPA 101 ( Life Safety Code). This deficiency affects all 27 patients in the facility.

Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, " Existing Health Care Occupancy, " 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 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 facility tour on February 1, 2011 between 12:30 p.m. and 4:00 p.m. the door to rooms 106, 110, 113, 114, 203, 206, 214 have gaps between the frame and the door. The door to these rooms were latching but was not resisting the passage of smoke.

Based on observation, the facility failed to provide exit signage that are in accordance with the National Fire Protection Association-NFPA 101 (Life Safety Code) for 3 of 18 exit signs. Exit signs shall indicate the direction of travel and shall be illuminated as to be legible in both normal and emergency lighting conditions. This deficiency affects the 27 residents on the Recovery unit.

Actual Code: NFPA 101, 2000 edition
NFPA 101:7.10.2 (Directional Signs)
7.10.2 A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
or
NFPA 101:7.10.5. (Illumination of signs)
7.10.5.1 Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

Findings:

During facility tour on February 1, 2011 between 12:30 p.m. and 3:00 p.m., the facility failed to provide exit signage that are lighted completely.

The following exit signs had bulbs that were not lit.
1. The exit sign by room 207 had a burnt bulb.
2. The exit sign by room 204 had a burnt bulb.
3. The exit sign by room 200 had a burnt bulb.