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Based on observations, the facility failed to ensure compliance with Chapter 19 of the 2012 edition of NFPA 101 Life Safety Code. Section 19.2.2.2.7 states that any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings Include:

While conducting the facility tour on 04/09/18 and 4/10/18 observations revealed that the West Unit's Dining Room corridor doors were held open by kick-type door stops.

As a result of the finding, the facility is found to be non-compliant with Chapter 19 Section 19.2.2.2.7.

The findings were confirmed by the Director of Maintenance (DOM) and reviewed with the DOM and Administrator during the exit conference.

Based on observations and confirmed by staff the facility failed to ensure compliance with Chapter 19.
Section 19.3.6.3.1 states that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 1-3/4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

Section 19.3.6.3.2 states that the requirements of 19.3.6.3.1 shall not apply where otherwise permitted by either of the following:
(1) Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain
flammable or combustible materials shall not be required to comply with 19.3.6.3.1.
(2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

Section 19.3.6.3.5 states that corridor doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

Findings Include:

On 04/09/18 and 04/10/18 the following were noted:

1. The corridor door to resident room #313 did not latch in its door frame.

2. The West Unit Dining Room corridor doors had a 3/16 inch gap at the meeting edge of the door leaf(s) when in the closed and latched position.

3. The corridor doors to each of the Medication Rooms on the West, North and South Units were equipped with a 36" wide door with a hinged 22" x 29" window (within the door). Each corridor door had a 1/4" unsealed void on the bottom edge of the window when in the closed position. Therefore, the doors were not capable of resisting the passage of smoke or otherwise classified as smoke-tight.

As a result of the finding the facility is found to be non-compliant with section 19.3.6.3.2(2).

The findings were confirmed by the Director of Maintenance (DOM) and reviewed with the DOM and Administrator during the exit conference.

Based on record review and confirmed by staff, the facility failed to ensure that doors are inspected as required. NFPA 101, Section 19.7.6 Maintenance and Testing refers to NFPA 101, Section 4.6.12.

NFPA 101, Section 4.6.12.1 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

NFPA 80, 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

NFPA 80, 5.2.3 Functional Testing.
NFPA 80, 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

NFPA 80, 5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.

NFPA 80, 5.2.4 Swinging Doors with Builders Hardware or Fire Door Hardware.
NFPA 80, 5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.
NFPA 80, 5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order
with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity

Findings Include:

On 4/09/18 and 4/10/18 while reviewing the facility's records, it was noted that a documented door inspection program has not been implemented. Facility staff stated they were aware of this requirement and that they inspected the doors, but do not have a documented program in place for door inspections.

As a result, the facility failed to comply with NFPA 80, Section 5.2.1 requiring documented annual door inspections.

The findings were confirmed by the Director of Maintenance (DOM) and reviewed with the DOM and Administrator during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure compliance with Chapter 19 of the 2012 edition of NFPA 101 " Life Safety Code " .

Section 19.7.8, "Portable Space Heating Devices" states that portable space heating-devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in non-sleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212 degrees F (100 degrees C).

Findings Include:

While conducting the facility tour on 04/09/18 and 4/10/18, portable electric space heaters with heating elements capable of exceeding 212 degrees F (100 degrees C) were located in the North Unit's Consult Room and in the South Unit's staff bathroom.

As a result, the facility failed to comply with section 19.7.8.

The findings were confirmed by the Director of Maintenance (DOM) and reviewed with the DOM and Administrator during the exit conference.