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Based on observations, the facility failed to properly protect corridors as per NFPA 101 Section 19.3.6.1. This deficiency practice affected the entire facility on day of survey.

Findings include:

On October 10, 2019 at 11:15AM, observation revealed open and unsealed holes in the corridor walls throughout the facility. All the corridor walls are required to be smoke tight and capable of resisting the passage of smoke throughout the facility. The facility was unsprinkled and not protected by fire sprinkler system.

Based on observation and testing, the facility failed to properly protect corridor openings as directed by NFPA 101 section 19.3.6.3.5. This deficiency practice affected the entire facility on day of survey.


Findings Include:

On October 10, 2019 at 10:35 AM, observation revealed an unapproved latching device the corridor door to the Respiratory Storage Room. The door to the Respiratory Storage Room was incapable of resisting the passage of smoke throughout the facility. The administrator was made aware of the problem during the exit conference.

Based on observations and interviews, the facility failed to properly maintain smoke barrier walls or the purpose of providing one half hour fire resistance as required by NFPA 101 section 19.3.7.3 This deficiency practice affected the entire facility on day of survey.

Findings include:

On October 10, 2019 at 11:30 AM, observation revealed unsealed penetrations in the smoke barrier ceiling of the facility. The smoke barrier ceiling was solid plaster ceiling above the lay in grid tiles of the facility. The facility was unsprinkled and not protected by fire sprinkler system.