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Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/or able to provide a positive latch in accordance with the LSC section 18.3.6.3.6. This deficient practice could potentially affect 20 occupants of the facility.

Findings include:

On 08/26/15 at approximately 10:00 AM, the following observations were made:
1. Observation revealed the door to 10B by the detox lounge did not provide a positive latch when closed.

2. Observation revealed the double doors to the clean linen and soiled linen rooms did not provide a positve latch to the inactive door lear without manually latching the door.

3. Observation revealed the door to the dining room from the corridor had a bolt in panic bar to disable the positive latch of the door.

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 30 occupants of the facility.

On 08/26/15 at approximately 11:00 AM, the following observation was made:
1. Observation revealed the cross corridor doors in the basement identified as 22A did not close to a smoke tight seal when checked.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect 50 occupants of the facility.

On 08/26/15 at approximately 10:30 AM, the following observations were made:
1. Observation revealed the door to the storage room in the kitchen was held open with a floor chock.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 08/26/15 at approximately 10:45 AM, the following observations were made:
1. Observation revealed the Oxygen cylinders in the med closet at the nurses station were not identified as full or empty.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/or able to provide a positive latch in accordance with the LSC section 18.3.6.3.6. This deficient practice could potentially affect 20 occupants of the facility.

Findings include:

On 08/26/15 at approximately 10:00 AM, the following observations were made:
1. Observation revealed the door to 10B by the detox lounge did not provide a positive latch when closed.

2. Observation revealed the double doors to the clean linen and soiled linen rooms did not provide a positve latch to the inactive door lear without manually latching the door.

3. Observation revealed the door to the dining room from the corridor had a bolt in panic bar to disable the positive latch of the door.

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 30 occupants of the facility.

On 08/26/15 at approximately 11:00 AM, the following observation was made:
1. Observation revealed the cross corridor doors in the basement identified as 22A did not close to a smoke tight seal when checked.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect 50 occupants of the facility.

On 08/26/15 at approximately 10:30 AM, the following observations were made:
1. Observation revealed the door to the storage room in the kitchen was held open with a floor chock.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 08/26/15 at approximately 10:45 AM, the following observations were made:
1. Observation revealed the Oxygen cylinders in the med closet at the nurses station were not identified as full or empty.