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Based on observations, the facility failed to maintain fire doors NFPA 101 sections 19.1.1.4.1, 19.1.1.4.2. This deficiency practice affected the entire facility on the day of survey.


Findings Include:

On September 28, 2016 at 9:00 AM, observation revealed the 1 ½ hour fire rated door separating the stairwell from the Doctor ' s Lounge in the 1st Floor Business Occupancy was damaged and was incapable of being fully closed. Additionally, observation revealed unsealed penetrations in the 1st Floor fire wall above the smoke doors near Operating Room 2.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observation and testing, the facility failed to properly protect corridor openings as required by NFPA 101 Chapter 19 3.6.3.1. This deficiency practice affected the entire facility on the day of survey.

Findings Include:

On September 28, 2016 between 11:00 AM and 12:00 PM, observation revealed the corridor doors to Rooms 2001, 2004, 2003 and 2036 had open penetrations. These corridor doors were incapable of resisting the passage of smoke.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.


19.3.6.3.1*

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

Based on observations, the facility failed to properly maintain smoke barrier walls for the purpose of providing 1 half hour fire resistance in accordance to NFPA 101 19.3.7.3, 19.3.7.5. This deficiency practice affected the entire facility on the day of survey.

Findings Include:

On September 28, 2016 at 1:50 PM, observation revealed unsealed penetrations above the ceiling in the smoke barrier wall on the 2nd Floor near Room 2045 and smoke barrier near the front of the Physical Therapy Area.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observations, the facility failed to properly protect hazardous areas in accordance NFPA 101 section 19.3.5.4. This deficiency practice affected the entire facility on the day of survey.

Findings Include:

On September 28, 2016 at 10:30 AM, observation revealed unsealed penetrations in the walls of the 2nd Floor Soiled Linen Room and 2nd Floor Clean Linen Room.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observations, the facility failed to provide readily accessible exit access as defined by NFPA chapter 7.2.1.5.4. These deficiency practices have the potential to affect the entire facility on the day of survey.

Findings Include:

On September 28, 20106 at 11:00 AM, observation revealed the doors to the following locations contain a locking device located above 48 inches from the finished floor:

1) P.T. Director
2) Dr ' s Lounges
3) Electrical Rooms 2-1, 2-2, 2-3
4) Break Room
5) Room 2045
6) Room 2046

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

7.2.1.5.4*
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations.

Based on observations, the facility failed to provide a complete manual fire alarm system as directed by NFPA 101 9.6, and NFPA 72 Table 4-4.4.1.1. These deficiency practices have the potential to affect the entire facility on the day of survey.

Findings Include:

On September 28, 2016 at 11:30 AM, observation revealed no audible fire alarm signaling device in the 1st Floor Elevator Lobby.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observations, the facility failed to maintain fire doors NFPA 101 sections 19.1.1.4.1, 19.1.1.4.2. This deficiency practice affected the entire facility on the day of survey.


Findings Include:

On September 28, 2016 at 9:00 AM, observation revealed the 1 ½ hour fire rated door separating the stairwell from the Doctor ' s Lounge in the 1st Floor Business Occupancy was damaged and was incapable of being fully closed. Additionally, observation revealed unsealed penetrations in the 1st Floor fire wall above the smoke doors near Operating Room 2.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observation and testing, the facility failed to properly protect corridor openings as required by NFPA 101 Chapter 19 3.6.3.1. This deficiency practice affected the entire facility on the day of survey.

Findings Include:

On September 28, 2016 between 11:00 AM and 12:00 PM, observation revealed the corridor doors to Rooms 2001, 2004, 2003 and 2036 had open penetrations. These corridor doors were incapable of resisting the passage of smoke.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.


19.3.6.3.1*

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

Based on observations, the facility failed to properly maintain smoke barrier walls for the purpose of providing 1 half hour fire resistance in accordance to NFPA 101 19.3.7.3, 19.3.7.5. This deficiency practice affected the entire facility on the day of survey.

Findings Include:

On September 28, 2016 at 1:50 PM, observation revealed unsealed penetrations above the ceiling in the smoke barrier wall on the 2nd Floor near Room 2045 and smoke barrier near the front of the Physical Therapy Area.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observations, the facility failed to properly protect hazardous areas in accordance NFPA 101 section 19.3.5.4. This deficiency practice affected the entire facility on the day of survey.

Findings Include:

On September 28, 2016 at 10:30 AM, observation revealed unsealed penetrations in the walls of the 2nd Floor Soiled Linen Room and 2nd Floor Clean Linen Room.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

Based on observations, the facility failed to provide readily accessible exit access as defined by NFPA chapter 7.2.1.5.4. These deficiency practices have the potential to affect the entire facility on the day of survey.

Findings Include:

On September 28, 20106 at 11:00 AM, observation revealed the doors to the following locations contain a locking device located above 48 inches from the finished floor:

1) P.T. Director
2) Dr ' s Lounges
3) Electrical Rooms 2-1, 2-2, 2-3
4) Break Room
5) Room 2045
6) Room 2046

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.

7.2.1.5.4*
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations.

Based on observations, the facility failed to provide a complete manual fire alarm system as directed by NFPA 101 9.6, and NFPA 72 Table 4-4.4.1.1. These deficiency practices have the potential to affect the entire facility on the day of survey.

Findings Include:

On September 28, 2016 at 11:30 AM, observation revealed no audible fire alarm signaling device in the 1st Floor Elevator Lobby.

The finding was acknowledged by the Administrator and verified by the Maintenance Supervisor during the exit interview.