| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 670031 | (X3) Date Survey Completed 01/12/2012 |
| Name of Provider or Supplier St Luke's Patients Medical Center | Street Address, City, State 4600 East Sam Houston Parkway South, Pasadena, TX | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| K0027 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Door openings in smoke barriers have at least a 20-minute fire protection rating or are at least 1¾-inch thick solid bonded wood core. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal sliding doors comply with 7.2.1.14. Swinging doors are arranged so that each door swings in an opposite direction. Doors are self-closing and rabbets, bevels or astragals are required at the meeting edges. Positive latching is not required. 18.3.7.5, 18.3.7.6, 18.3.7.8 This STANDARD is not met as evidenced by: based on observation during the facility and discussions with the director of plant operations on 01/12/1012, it was noted that a set of cross-corridor smoke barrier doors did not shut completely during a testing of the facility fire alarm system. They failed to close together to form a smoke resistant barrier due to acombination of air flow differential for the HVAC system within the hallway on either side of the set of doors, and self closing devices not being adjusted properly to close against the air pressure differential. |