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Based on observation of all doors opening onto the corridor on 02/24/2015, the facility failed to maintain corridor doors that resist the passage of smoke. Findings include:

1. Material Management had two corridor entrance doors and each door had four (4) ¼ " diameter holes in the door through which this surveyor could see daylight.
2. Drink storage room corridor door on the main hall had a ½ " gap around the door hardware latch set.


This deficiency impacts 2 of 5 smoke compartments.
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2000 NFPA 101, 19.3.6.3.1*
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Based on the observation of all smoke barriers on 2/24/2015, the facility failed to maintain smoke barriers that would provide at least a 1/2 hour fire resistance rating. Findings include:

Unsealed penetrations around a water line in the smoke barrier by the Chapel.

The deficiency impacted 2 of 5 smoke compartments.
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Review of 2000 NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Review of 2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
.

Based on observation on 02/24/2015, the facility failed to maintain self closing devices for corridor doors to hazardous areas and maintain separation of hazardous areas. Findings include:

A) Unsealed penetrations around water line from the fuel-fired heater, this line runs through the wall in mechanical room one.


34000

B) In Central Sterile (200 SF +) room is currently being used to store combustible material. Corridor door need a self closing closer installed on the door.

This deficiency impacts 2 of 5 smoke compartments. Failure to maintain smoke compartments increases the risk of death or injury due to fire.
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2000 NFPA 101, 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
.

Based on observation on 02/24/2015, the facility failed to maintain the fire sprinkler system. Findings include:

In Storage room behind Nurse's station East side was observed with a ½" gap in the ceiling tile around escutcheon plate.

This deficiency impacts 1 of 5 smoke compartments.
_____________
2000 NFPA 101, 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.
.

Based on observation on 02/24/2015, of portable fire extinguishers none of the extinguishers had been inspected for the month of January 2015. Findings include:

Observation revealed that fire extinguishers in the facility had not been inspected for the month of January 2015.

This deficiency impacts 5 of 5 smoke compartments
______________
2000 NFPA 101, 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 1998, 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded. 1998 NFPA 10, 4-4.4* Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Based on observation on 02/24/2015, of portable fire extinguishers none of the extinguishers had been inspected for the month of January 2015. Findings include:

Observation revealed that fire extinguishers in the facility had not been inspected for the month of January 2015.

This deficiency impacts 5 of 5 smoke compartments
______________
2000 NFPA 101, 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 1998, 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded. 1998 NFPA 10, 4-4.4* Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.
.

Based on observation on 02/24/2015, the facility failed to monitor the facility for the use of portable heating devices.

Doctor's sleep room East Hall had a portable heater plugged into a wall outlet.

This deficiency impacts 1 of 5 smoke compartments.
__________________
2000 NFPA 101, 19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).

.

Based on observation of all doors opening onto the corridor on 02/24/2015, the facility failed to maintain corridor doors that resist the passage of smoke. Findings include:

1. Material Management had two corridor entrance doors and each door had four (4) ¼ " diameter holes in the door through which this surveyor could see daylight.
2. Drink storage room corridor door on the main hall had a ½ " gap around the door hardware latch set.


This deficiency impacts 2 of 5 smoke compartments.
______________
2000 NFPA 101, 19.3.6.3.1*
.

Based on the observation of all smoke barriers on 2/24/2015, the facility failed to maintain smoke barriers that would provide at least a 1/2 hour fire resistance rating. Findings include:

Unsealed penetrations around a water line in the smoke barrier by the Chapel.

The deficiency impacted 2 of 5 smoke compartments.
---------------------------------------
Review of 2000 NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Review of 2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
.

Based on observation on 02/24/2015, the facility failed to maintain self closing devices for corridor doors to hazardous areas and maintain separation of hazardous areas. Findings include:

A) Unsealed penetrations around water line from the fuel-fired heater, this line runs through the wall in mechanical room one.


34000

B) In Central Sterile (200 SF +) room is currently being used to store combustible material. Corridor door need a self closing closer installed on the door.

This deficiency impacts 2 of 5 smoke compartments. Failure to maintain smoke compartments increases the risk of death or injury due to fire.
_____________
2000 NFPA 101, 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
.

Based on observation on 02/24/2015, the facility failed to maintain the fire sprinkler system. Findings include:

In Storage room behind Nurse's station East side was observed with a ½" gap in the ceiling tile around escutcheon plate.

This deficiency impacts 1 of 5 smoke compartments.
_____________
2000 NFPA 101, 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.
.

Based on observation on 02/24/2015, of portable fire extinguishers none of the extinguishers had been inspected for the month of January 2015. Findings include:

Observation revealed that fire extinguishers in the facility had not been inspected for the month of January 2015.

This deficiency impacts 5 of 5 smoke compartments
______________
2000 NFPA 101, 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 1998, 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded. 1998 NFPA 10, 4-4.4* Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Based on observation on 02/24/2015, of portable fire extinguishers none of the extinguishers had been inspected for the month of January 2015. Findings include:

Observation revealed that fire extinguishers in the facility had not been inspected for the month of January 2015.

This deficiency impacts 5 of 5 smoke compartments
______________
2000 NFPA 101, 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 1998, 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded. 1998 NFPA 10, 4-4.4* Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.
.

Based on observation on 02/24/2015, the facility failed to monitor the facility for the use of portable heating devices.

Doctor's sleep room East Hall had a portable heater plugged into a wall outlet.

This deficiency impacts 1 of 5 smoke compartments.
__________________
2000 NFPA 101, 19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).

.