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Based on observation the facility failed to provide doors that close, latch, or resist the passage of smoke for 17 doors in the facility as per NFPA 101 (Life Safety Code). This deficiency could affect all 175 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 tour of the facility from April 2 - 4, 2013, the door to the following rooms did not resist the passage of smoke.

1. The doors rooms 1001, 1002, 1004, 1007, 1019, 1021, 1023, 1025, 807, 712, 420, 318, 321, 323, 324, & 325 have gaps between the door and the frame. This gap would allow smoke to move between the room and the corridor.

Based on observation the facility failed to provide complete protection for 2 hazardous areas as per National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency could have the potential to cause harm to all 31 patients on the 7th floor of the facility.

Note: NFPA 101, 2000 Edition:
NFPA 101, Chapter 3, "Protection" 19.3.5.4 if the hazardous areas is sprinkled then the walls and doors to the hazardous area shall be smoke resistive and the door shall be self-closing.

Findings:

During a tour of the facility from April 2 - 4, 2013, it was observed that the following hazardous areas did not have doors that were positive latching or closing fully.

1. The door to the soiled linen room across from the nurse station is not positive latching.
2. The door to the clean linen room across from the nurse station is not positive latching.

Based on observation the facility failed to provide doors that close, latch, or resist the passage of smoke for 17 doors in the facility as per NFPA 101 (Life Safety Code). This deficiency could affect all 175 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 tour of the facility from April 2 - 4, 2013, the door to the following rooms did not resist the passage of smoke.

1. The doors rooms 1001, 1002, 1004, 1007, 1019, 1021, 1023, 1025, 807, 712, 420, 318, 321, 323, 324, & 325 have gaps between the door and the frame. This gap would allow smoke to move between the room and the corridor.

Based on observation the facility failed to provide complete protection for 2 hazardous areas as per National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency could have the potential to cause harm to all 31 patients on the 7th floor of the facility.

Note: NFPA 101, 2000 Edition:
NFPA 101, Chapter 3, "Protection" 19.3.5.4 if the hazardous areas is sprinkled then the walls and doors to the hazardous area shall be smoke resistive and the door shall be self-closing.

Findings:

During a tour of the facility from April 2 - 4, 2013, it was observed that the following hazardous areas did not have doors that were positive latching or closing fully.

1. The door to the soiled linen room across from the nurse station is not positive latching.
2. The door to the clean linen room across from the nurse station is not positive latching.