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NFPA 80 Standard for Fire Doors and Other Opening Protectives
4.2.1 Listed items shall be identified by a label.
4.2.2 Labels shall be applied in locations that are readily visible and convenient for identification by the AHJ after installation of the assembly.
4.2.3 The label or listing shall be considered evidence that sampling of such devices or materials have been evaluated by tests and that such devices or materials are produced under an in-plant, follow-up inspection programs.
5.2 Inspections
5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.
5.2.4 Swinging Doors with Builders Hardware of Fire Door Hardware.
5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of the door assembly.
5.2.4.2 As a minimum, the following items shall be verified.
(1) No open holes or breaks exist in the surface of the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self closing device is operational: that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

Based on observations and interview, it was determined the facility failed to ensure one 90-minute fire-rated door assembly could resist the passage of smoke and the effects from fire.

Findings include:

Observations during tour on 01/19/23 between 12:30 p.m. and 12:45 p.m. with Staff A (Operations Manager) and Staff B (Operations Support Manager) revealed the 90-minute fire rated door assembly (labeled # 5), located between the cafe and the sitting area, is installed in a 1-hour smoke barrier wall and failed to have a smoke resistant seal when fully closed in the latched position. The bottom of the door, on the latching side, has a one inch gap between the door panel and the door frame when fully closed and will not resist the passage of smoke.

Interview on 01/19/23 with Staff A and Staff B confirmed the above findings, location, and existing conditions.

NFPA 101 LIFE SAFETY CODE (2012 edition)
7.2.9.4 Emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110 STANDARD for EMERGENCY and STANDBY POWER SYSTEMS (2010 edition).
7.9.3.1.1 Testing of the emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the AHJ (Authority Having Jurisdiction).
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3).

NFPA 110 STANDARD for EMERGENCY and STANDBY POWER SYSTEMS (2010 edition)
7.3 Lighting
7.3.1 The level 1 or level 2 EPS (Emergency Power Supply) equipment locations shall be provided with battery powered emergency lighting.
This requirement shall not apply to units located outdoors in enclosures that do not include walk in access.

Based on observations and interview, it was determined the facility failed to ensure one battery powered emergency lighting unit could be activated for testing.

Findings include:

Observations during tour on 01/19/23 between 10:30 a.m. and 10:45 a.m. with Staff A (Operations Manager) and Staff B (Operations Support Manager) revealed the battery powered emergency lighting unit, located in the lower level main electrical room (off the main boiler room), failed to operate when the testing button was activated. The battery powered lighting unit is placed to illuminate the Automatic Transfer Switch for the emergency generator.

Interview on 01/19/23 with Staff A and Staff B confirmed the above findings, location, and existing conditions.

Based on observations and interview, it was determined the facility failed to ensure four doors, protecting hazardous areas, could automatically close to a latched position.

Findings include:

Observations during tour on 01/19/23 between 10:30 a.m. and 10:55 a.m. with Staff A (Operations Manager) and Staff B (Operations Support Manager) revealed four separate doors located between the lower level main boiler room, and three support areas, failed to be equipped with automatic door closing devices, or being capable of closing to a full latched position.

The four doors and conditions off the Boiler room are as follows:

1. The door assembly to the main Electrical room failed to be equipped with an automatic door closing device but was found in the full closed and latched position.

2. The door assembly to the large facility workshop failed to be equipped with an automatic door closing device but was found in the full closed and latched position.

3. The door assembly protecting the small facility workshop failed to be equipped with an automatic door closing device or being able to close to a latched position. The bottom of the door panel strikes the door frame, preventing a full closed position.

4. The door assembly protecting the medical air compressor room failed to be equipped with an automatic door closing device or being able to close to a latched position. The bottom of the door panel strikes the door frame, preventing a full closed position. The door frame has been twisted out of alignment on the bottom latching side.

Interview on 01/19/23 with Staff A and Staff B confirmed the above findings, locations, and existing conditions.

NFPA 101 Life Safety Code (2012 edition)
8.5 Smoke Barriers
8.5.2.1 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 by use of a combination thereof.
8.5.2.2 Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Based on observations and interview, it was determined the facility failed to ensure three smoke barrier locations could resist the passage of smoke or the effects from fire.

Findings include:

Observations during tour on 01/19/23 between 12:30 p.m. and 2:15 p.m. with Staff A (Operations Manager) and Staff B (Operations Support Manager) revealed the following three 1-hour smoke barrier locations and conditions that will fail to resist the passage of smoke or the effects from fire:

1. Above the suspended ceiling over the facility identified door # 4, has an unprotected penetration of a 1" metal electrical conduit and an unprotected penetration of a bundle of wires with exposed pink fiberglass insulation.

2. Above the suspended ceiling over the facility identified door # 13, has an unprotected penetration of a white electrical wire (approximate 1" hole).

3. Above the suspended ceiling over the facility identified door # 10, has an unprotected penetration of a 1" metal electrical conduit and a 2" empty hole through the existing masonry block wall.

Interview on 01/19/23 with Staff A and Staff B confirmed the above findings and existing conditions.

NFPA 70, 400.8. (Extension Cords) Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure.

NFPA 99 HEALTH CARE FACILITIES
3-3.2.1.2 (d) (2) Minimum number of receptacles..... There shall be a sufficient number of receptacles located as to avoid the need for extension cords or multiple outlet adapters.

STATE of NH DEPARTMENT of SAFETY INFORMATIONAL BULLITEN 2008-02
The use of non-compliant plug strips presents a danger to the occupant's due to their design and the atmosphere they are being used in.

Based on observations and interview, it was determined the facility failed to ensure multiple (small) refrigerators are plugged into a fixed receptacle (outlet) in two separate locations.

Findings include:

Observations during tour on 01/19/23 between 8:00 a.m. and 12:45 p.m. with Staff A (Operations Manager) and Staff B (Operations Support Manager) revealed nine personnel size refrigerators are plugged into three separate power strips in the nursing preparation room of the short stay unit (unit not currently in use), located on the shelving unit. Additionally six personnel size refrigerators are plugged into two separate power strips in the Med Surge observations bay, located on a single shelving unit.

Interview on 01/19/23 with Staff A and Staff B confirmed the above findings, locations and existing conditions.