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Based on observation the facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Findings Include:

On November 8, 2011, the surveyor accompanied by the Chief Executive Officer, and Maintenance Staff observed that the following smoke seals were worn on the following doors:

1. The smoke seals on the corridor smoke barrier doors located at the Nursing Supervisor Office and Elevators on the first floor were worn and created a gap greater than 1/8 inch.

2. The smoke seals on the corridor smoke barrier doors located at the Clinical Coordinators Office on second floor were torn and created a gap greater than 1/8 inch.

During the exit conference on November 8, 2011, the above findings were again acknowledged by the Chief Executive Officer, Administrator, Safety Officer, Director of Maintenance, and Maintenance Staff.

Failure to maintain the smoke seals on corridor doors will allow smoke to contaminate smoke zones not directly effected by the fire which will cause harm to patients and staff.

Based on observation the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.2.1 and Section 18.2.3.3, Section 18.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times."

Findings include:

On November 8, 2011, the surveyor, accompanied by the Chief Executive Officer and Maintenance Staff, observed storage of Medication Carts and a shelving unit in the following exit corridors:

1. Third floor MCU wing there were two medication carts and a wall storage unit in the eight foot corridor reducing the corridor width to 5 feet 6 inches.

2. Second floor B wing two medication carts plugged into the corridor electrical receptacles which reduced the corridor width to 5 feet 8 inches at the point of storage.

3. Second floor C wing two medication carts plugged into the corridor electrical receptacles which reduces the corridor width to 5 feet 8 inches at the point of storage.

During the exit conference on November 8, 2011 the above findings were again acknowledged by the Chief Executive Officer, Administrator, Safety Officer, Director of Maintenance, and Maintenance Staff.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and could cause harm to the patients and staff.