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Based upon observation, review of life safety plans and interview the facility failed to ensure complete smoke barrier protection. Failure to provide complete smoke barrier protection could lead to smoke and fire gases passing between compartments and negatively impacting protect in place strategies. This deficient practice affected five patients and staff in two of three smoke compartments. The facility is licensed for 40 beds and had a census of 37 on October 26, 2015.

Findings include:

During the facility tour on 10/26/15 between 1:00 and 4:00 PM observation and operational testing of the door to the activities of daily living (room 107) revealed the door was not self-closing. Review of the life safety drawings indicated the door was a part of the smoke barrier separation wall between smoke compartment #2 and #3. When asked, facility plant personnel indicated they where not aware the door was required to be self-closing.

Actual NFPA standard:

NFPA 101 -2000

18.3.7.6*
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.

A.18.3.7.6
Smoke barriers might include walls having door openings other than cross-corridor doors. There is no restriction in the Code regarding which doors or how many doors form part of a smoke barrier. For example, doors from the corridor to individual rooms are permitted to form part of a smoke barrier.