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NFPA 101:8.3.5.1.2 The maximum nominal diameter of the penetrating item, as indicated in 8.3.5.1.1(4)(a) through (d), shall not be greater than 4 in. (100 mm) and shall not exceed an aggregate 100 in.2 (64,520 mm2) opening in any 100 ft2 (9.3 m2) of floor or wall area.

NFPA 101:8.5.2.2 Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

NFPA 101:8.3.5 Penetrations. The provisions of 8.3.5 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations in fire walls, fire barrier walls, and fire resistance-rated horizontal assemblies. The provisions of 8.3.5 shall not apply to approved existing materials and methods of construction used to protect existing through-penetrations and existing membrane penetrations in fire walls, fire barrier walls, or fire resistance-rated horizontal assemblies, unless otherwise required by Chapters 11 through 43.

NFPA 101: 8.3.5.1 Firestop Systems and Devices Required. Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through- Penetration Firestops, at a minimum positive pressure differential of 0.01 in. water column (2.5 N/m2) between the exposed and the unexposed surface of the test assembly.

NFPA 101:8.3.5.1.1 The requirements of 8.3.5.1 shall not apply where otherwise permitted by any one of the following:
(1) Where penetrations are tested and installed as part of an assembly tested and rated in accordance with ASTM E 119, Standard Test Methods for Fire Tests of Building Construction and Materials, or ANSI/UL 263, Standard for Fire Tests of Building Construction and Materials
(2) Where penetrations through floors are enclosed in a shaft enclosure designed as a fire barrier
(3) Where concrete, grout, or mortar has been used to fill the annular spaces around cast-iron, copper, or steel piping that penetrates one or more concrete or masonry fire resistance- rated assemblies and both of the following criteria are also met:
(a) The nominal diameter of each penetrating item shall not exceed 6 in. (150 mm), and the opening size shall not exceed 1 ft2 (0.09 m2).
(b) The thickness of the concrete, grout, or mortar shall be the full thickness of the assembly.

Based on visual observation, the facility failed to maintain the space between the penetrating item and the smoke barrier. The penetrating item must be properly filled with a material (intumescent) that is capable of maintaining the fire resistance rating in accordance with ASTM E-814 or UL1479 designed for wall cable, wire type penetrations of the smoke barrier. Unprotected penetrations would permit the movement of smoke / fire from one compartment to the other in the facility. The deficient practice had the potential to affect seventeen of seventeen patients.

Findings:

During the facility tour on September 27, 2022 between the hours of 8:45 a.m. 2:30 p.m. the smoke barrier located above the cross corridor double door suspended ceiling nearest the nursing station had a HVAC duct that did not extend more than three feet beyond the smoke barrier wall and a steel pipe that was vertically embedded in the rated smoke barrier wall.



The interview with the facility manager revealed the facility was not aware that the smoke barrier had a HVAC duct penetration and a steel pipe penetration that was not properly boxed with 5/8 type "x" sheetrock to form a continuous seal in accordance with NFPA 101.

Based on visual observation the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect seventeen of seventeen patients.

Findings:

During the facility tour on September 27, 2022 between the hours of 8:45 a.m. 2:30 p.m. the generator was not provided with a remote manual stop and remote manual signage located outside the weatherproof enclosure.

NFPA 110:5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

NFPA 101:A.5.6.5.6 For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

NFPA 110:5.6.5.6.1 The remote manual stop station shall be labeled.


The interview with the maintenance director revealed the facility was not aware that a remote manual stop locate outside the weatherproof enclosure for emergency generators was required.