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Based on visual observation the facility failed to maintain the self closing smoke resisting corridor door in accordance with NFPA 101:8.4. Hazardous areas are required to be constructed to resist the passage of smoke. The deficient practice had the potential to affect 4 of 4 patients.

Findings:

During the facility tour on 1/8/2018 between the hours of 9:30 am to 2:30 pm it was observed the Central Supply room number 407 corridor door is not self - closing properly. NFPA 101:8.4.3.5 states, "Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8."

Interview with the Administrator revealed the facility was not aware the hazardous area storage room door 407 was not self closing properly.

Based on visual observation the facility failed to provide corridor doors that were not latching in the frame of the residents sleeping room doors as per NFPA 101:3.6.3.5. When the sleeping room doors latch a smoke resistive seal is formed to protect the room's occupants. The deficient practice had the potential to affect 4 of 4 patients 1 of 1 corridors having sleeping room doors that were deficient.

Findings:

During the facility tour on 1/8/2018 for the only hospital wing between the hours of 9:30 am to 2:30 pm the observations noted patient sleeping room 409 corridor door was not fully latching properly. NFPA 101:3.6.3.5 (1) states "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"(lbf / pound - force).

Interview with the Administrator revealed the facility was aware the door to Room 407 was not latching in the frame.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 4 of 4 patients.
1 of 2 smoke barriers were deficient.

Findings:

During the facility tour on 1/8/2018 between the hours of 9:30 am to 2:30 pm it was observed in the smoke barrier attic area, nearest the nursing station, had seven separate smoke barrier penetrations of various sizes. NFPA 101:8.5.2.2 states, "Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

Interview with the Administrator revealed the facility was not aware of the unsealed penetrations.