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Tag No.: K0011
8.2.2.2, NFPA 101, LIFE SAFETY CODE
Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above suspended ceilings, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221 STANDARD for FIRE WALLS and FIRE BARRIER WALLS.
Based on observation, record review and interview the facility failed to ensure that 1 (one) Fire Door (90 minute rating) is installed in a 2-hour fire barrier.
Findings include:
Observations during tour on 02/18/16 between 9:30 a.m. and 11:30 a.m. with Staff A (Maintenance Supervisor) and Staff B (Maintenance Director) revealed that the 2 hour fire barrier runs along the SCU (Special Care Unit) and partially into the SCU. The nurse supply/storage room inside the SCU is part of the 2-hour fire barrier. The Fire Door and door closing device into the supply/storage room has been removed. The door frame is still present.
Record review of the facilities floor plans revealed the locations of the 2 hour fire barriers.
Interview with Staff A and Staff B at the time of observation confirmed the location of the fire barrier and above findings.
Tag No.: K0017
Based on observations and interview the facility failed to ensure that fire/smoke barriers are maintained and are complete to prevent the passage of smoke.
Findings include:
Observations during tour on 02/18/16 between 9:30 a.m. and 2:00 p.m. with Staff A (Maintenance Supervisor) and Staff B (Maintenance Director) revealed the following 4 (four) fire/smoke barrier locations with unprotected penetrations through the walls. All locations are above the suspended ceiling.
Locations are as follows:
1. Over door # ML 27 (Basement Level) there are 2 (two) pipe sleeve's (approximately 4") penetrating through the wall with "IT" (Information Technology) cables and electrical wires that are not sealed to prevent the passage of smoke. There are a couple of cinder blocks with small piece's broken off which will not prevent the passage of smoke.
2. Over door # 143 there is an FMC (Flexible Metal Conduit) and "IT" wires that are not sealed and will not prevent the passage of smoke.
3. Inside the Medical Gas Manifold room there is 1 (one) hot water supply pipe and 1 (one) hot water return pipe penetrating the wall that are not sealed and will not prevent the passage of smoke.
4. Over the Specialty Services door there is a FMC (Flexible Metal Conduit) and a 2" inch hole penetrating through the wall that will not prevent the passage of smoke.
Interview with Staff A and Staff B at the time of observations confirmed the above findings and locations.