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Based on observation and interview with staff, the facility failed to provide corridors separated from use areas by walls constructed with at least 1/2 hour fire resistance rating.
Section 19.3.6.2.1, Exception No. 1 reads "in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke." Findings:

1) The suspended acoustical ceiling was found to have cracked, broken, warped, and water damaged tiles at various locations in the facility.

Based on observation and interview with staff, the facility failed to provide corridor doors with a means suitable for keeping the door closed. Findings:

1) The dutch door between the corridor and the room adjacent to the lab does not meet the requirements of 19.3.6.3.6. The upper leaf and lower leaf are required to have a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. This door does not meet these requirements.

2) There is no latching hardware on several doors leading into rooms off the corridors. Section 19.3.6.3.2 requires doors to be provided with a means suitable for keeping the door closed.

Based on observation and interview with staff, the facility failed to provide at least two smoke compartments with smoke barriers having at least one-half hour fire resistance rating. Section 19.3.7.3 states that "any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than one-half hours." Findings:

1) Penetrations and un-rated materials were found in the smoke compartment wall.

Based on observation and interview with staff, the facility failed to provide doors in smoke barriers that are self-closing or automatic closing in accordance with 19.2.2.2.6, which requires the automatic sprinkler system and the fire alarm system to initiate the closing action of all doors in smoke barriers. Findings:

1) The corridor doors in the smoke barrier (smoke compartment wall) did not close upon activation of the alarm system.

Based on observation and interview with staff, the facility failed to provide hazardous areas protected in accordance with 19.3.2.1, which requires doors to be self-closing or automatic-closing. Findings:

1) Central Supply is considered a hazardous area per 19.3.2.1, having an area greater than 50 square feet used for storage of combustible supplies. The door into Central Supply is not self-closing.

Based on observation and interview with staff, the facility failed to provide the clear and unobstructed width through the length of the 8' corridors. Findings include:

1) The remodeled nurse station extends into the adjacent corridors, reducing the clear width of these corridors. The nurse station was remodeled without OSDH Plan Review approval. The nurse station remodel would have been considered "new construction" and would have been reviewed under Chapter 18, New Health Care Occupancies in NFPA 101, which requires the 8' clear width corridors.

Based on observation and interview with staff, the facility failed to provide a fire alarm system tested and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Findings:

1) The fire alarm panel was last inspected in June 2008. An annual inspection is required, refer to NFPA 72 National Fire Alarm Code, Table 10.3.1.

Based on observation and interview with staff, the facility failed to provide cooking facilities protected in accordance with 9.2.3. Findings:

1) The range hood systems report dated 2-2-09 reported deficiencies that have not been corrected: the system is not tied into the building fire alarm system, and grease filters need to be cleaned.

Based on observation and interview with staff, the facility failed to provide a Type 1 Essential Electrical System in accordance with NFPA 99. Findings:

1) Section 3-4.1.1.15 states that "a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station." The facility does not have a remote annunciator.