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Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting approximately 17 patients in one of two of smoke zones. The facility has a capacity of 40 with a census of 38 at the time of survey.

Findings include:

During the survey on February 20, 2018 at 9:20 a.m., it is observed that the door from patient room 110 to the corridor does not latch.

The Maintenance Director was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction and the following requirements also shall apply:

(1) 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.
(2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. 2012 NFPA 101, 19.3.6.3.5