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Based on observation and interview, the facility failed to ensure doors protecting corridor openings are of substantial construction capable of resisting fire for at least 20 minutes, in accordance with 19.3.6.3.1. This deficient practice potentially affected patients, staff and visitors entering corridor areas in the northwest portion of the facility. The facility census was 8.

Findings included:

1. Observation on 01/29/13 at 2:00 PM showed a gap of 3/8 inch between the top and bottom halves of a wooden "Dutch" door to a large room identified as Central Supply. Both the top and bottom halves of the door were independently free swinging and not on an automatic closer to ensure the doors would close automatically and stay closed when not attended. Neither half of the door was equipped with a magnetic device designed to release in the event of a fire alarm. The top half of the door was independent and lacked an astragal or bevel to connect it with the bottom half and force the bottom half closed to seal off the room and prevent the spread of smoke from the room into the adjacent corridors.

During an interview on 01/29/13, Staff C, Director of Facilities, stated that they could fix the door to be smoke-tight and meet the requirements of a corridor door. He stated that maintenance would check the size of the door against those they had in storage and could possibly replace the door with a single leaf door.