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Based on observation and staff interview, the facility failed to ensure that the building meets Type II (222) building construction by having an unprotected wood framed storage area attached to the building and unprotected wood stairs attached to the building. This deficient practice affected all patients, visitors and staff in the building. Facility census was 4 and capacity of 18.

Findings are:
Observations on 9-29-10 from 10:30 a.m. to 2:00 p.m. revealed:
a) An unprotected wood framed storage area, used for biohazard waste, attached to the exterior of the building.
b) A set of unprotected wood stairs to access the roof that were attached to the building.
During an interview at the time of observation Maintenance A confirmed the findings.

NFPA Standard:
Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2 (See 8.2.1)2000, NPFA 101, 19.1.6.2

Based on observation and interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. They shall also resist the passage of smoke. This deficient practice affected all residents, staff, and visitors of the facility. The facility census was 4 and capacity of 18.

Findings are:
Observation on 9-29-10 from 10:30 a.m. to 2:00 p.m. revealed that the corridor door to Patient Room 1 failed to latch when closed. During an interview at the time of observation Maintenance A confirmed the findings.


NFPA Standard:
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 1 ? inch thick, solid-bonded core wood or of construction that resist 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 inch shall be permitted for corridor doors. 2000 NFPA 101, 19.3.6.3

Based on interview and observation the facility failed to provide smoke protection for hazard areas, by not ensuring all doors to hazardous areas positively latched. This deficient practice affected all patients, visitors and staff that use the Physical Therapy area. The facility census was 4 and capacity of 18.

Findings are:
Observations on 9-29-10 from 10:30 a.m. to 2:00 p.m. revealed that the door to the storage room in physical therapy failed to latch when closed. During an interview at the time of observation Maintenance A confirmed the findings.

NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Hazardous areas without sprinkler protection require one-hour fire resistance rating construction and doors shall be 3/4 hour fire rated with self closers and positive latches. 2000 NFPA 101, 19.3.2.1

Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72 National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4) .
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.
2000 NFPA 101, 7.2.1.9.2

Based on observation and staff interview, the facility failed to ensure that the building meets Type II (222) building construction by having an unprotected wood framed storage area attached to the building and unprotected wood stairs attached to the building. This deficient practice affected all patients, visitors and staff in the building. Facility census was 4 and capacity of 18.

Findings are:
Observations on 9-29-10 from 10:30 a.m. to 2:00 p.m. revealed:
a) An unprotected wood framed storage area, used for biohazard waste, attached to the exterior of the building.
b) A set of unprotected wood stairs to access the roof that were attached to the building.
During an interview at the time of observation Maintenance A confirmed the findings.

NFPA Standard:
Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2 (See 8.2.1)2000, NPFA 101, 19.1.6.2

Based on observation and interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. They shall also resist the passage of smoke. This deficient practice affected all residents, staff, and visitors of the facility. The facility census was 4 and capacity of 18.

Findings are:
Observation on 9-29-10 from 10:30 a.m. to 2:00 p.m. revealed that the corridor door to Patient Room 1 failed to latch when closed. During an interview at the time of observation Maintenance A confirmed the findings.


NFPA Standard:
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 1 ? inch thick, solid-bonded core wood or of construction that resist 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 inch shall be permitted for corridor doors. 2000 NFPA 101, 19.3.6.3

Based on interview and observation the facility failed to provide smoke protection for hazard areas, by not ensuring all doors to hazardous areas positively latched. This deficient practice affected all patients, visitors and staff that use the Physical Therapy area. The facility census was 4 and capacity of 18.

Findings are:
Observations on 9-29-10 from 10:30 a.m. to 2:00 p.m. revealed that the door to the storage room in physical therapy failed to latch when closed. During an interview at the time of observation Maintenance A confirmed the findings.

NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Hazardous areas without sprinkler protection require one-hour fire resistance rating construction and doors shall be 3/4 hour fire rated with self closers and positive latches. 2000 NFPA 101, 19.3.2.1

Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72 National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4) .
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.
2000 NFPA 101, 7.2.1.9.2