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42 CFR 483.70 (a)

Based on observations, on 9/1/15 at approximately 11 AM onward, the following deficiencies were noted: The doors protecting corridor openings was non-compliant, specific findings include;
A. Doors to rooms 223 and 227 did not latch in it's frame.
B. Doors to rooms 215 and 216 did not close with less than 15 pounds pressure due to object over door.
C. Door to room 236 A did not close with less than 15 pounds pressure. This item was corrected during the survey.
D. Door to room 250 was not provided with a strike plate. This item was corrected during the survey.
E. Door to room 229 had a door stop. It was discussed with the patient who said that a family member had placed the door stop.

Reference: NFPA 101, 19.3.6.3 There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed.
Reference NFPA 101, 7.2.1.4.5 The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbs (22 N). These forces shall be applied at the latch stile.

This deficiency affected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 483.70 (a)

Based on observations, on 9/1/15 at approximately 11 AM onward, the following deficiencies were noted: The means of egress was non-compliant, specific findings include; corridor door to room 244 swings into the corridor without a listed closure and the door does not swing 180 degrees but leaves a projection of approximately 12" into the corridor.

Reference 2000 NFPA 101 Section 7.2.1.4.4 states during its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open.

This deficiency affected one of two smoke compartments. Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 483.70 (a)

Based on observations, on 9/1/15 at approximately 11 AM onward, the following deficiencies were noted: The oxygen storage was non-compliant, specific findings include; the oxygen storage room at the nurses staff toilet had combustible items, mail room and coat rack stored within 5'-0" of the E sized O2 tanks.

Ref: 2000 NFPA 101 Section 18.3.2.4, 1999 NFPA 99 Section 8-3.1.11.2, CMS S&C 07-10
In storage locations protected by automatic sprinkler system where the volume of oxygen is less than 3000 cubic feet (approx. 120 E sized cylinders) oxidizing gases shall be separated from combustible materials by a minimum distance of 5'-0" or be enclosed with 1/2 hour fire resistant rated construction or in a flammable liquid storage cabinet. Volumes of oxygen less than 300 CF of O2 (approx. 12 E sized cylinders) may be kept in each smoke compartment at location open to the corridor.

This deficiency affected one of two smoke compartments. Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.