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Based on observation and staff interviews, the facility is failing to assure that corridor doors resist the passage of smoke, allowing the spread of smoke. This affects approximately 0 patients in 1 of 8 smoke zones. The facility has a capacity of 25 with a census of 21.

Findings Include:

During the tour on 08-05-2013 the following is observed:

--1. At 11:20 A.M., the corridor door to the Patient Financial Services area has a small hole through it just above the door knob.

The Facility Management Officer, the Electrician, and the HVAC Mechanic was present and acknowledge the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview, the facility is failing to assure that smoke barrier walls above the ceiling are properly sealed, failing to provide the proper separation in order to prevent the spread of smoke and fire. This deficiency affects approximately 0 patients in 2 of 8 smoke zones. The facility has a capacity of 25 with a census of 21.

Findings Include:

During the tour on 08-05-2013 the following is observed:

--1. At 2:03 P.M., the smoke barrier wall above the dropped ceiling by the pharmacy has a small hole through it.

The Facility Management Officer, the Electrician, and the HVAC Mechanic was present and acknowledge the finding.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interviews, the facility is failing to assure that corridor doors resist the passage of smoke, allowing the spread of smoke. This affects approximately 0 patients in 1 of 8 smoke zones. The facility has a capacity of 25 with a census of 21.

Findings Include:

During the tour on 08-05-2013 the following is observed:

--1. At 11:20 A.M., the corridor door to the Patient Financial Services area has a small hole through it just above the door knob.

The Facility Management Officer, the Electrician, and the HVAC Mechanic was present and acknowledge the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview, the facility is failing to assure that smoke barrier walls above the ceiling are properly sealed, failing to provide the proper separation in order to prevent the spread of smoke and fire. This deficiency affects approximately 0 patients in 2 of 8 smoke zones. The facility has a capacity of 25 with a census of 21.

Findings Include:

During the tour on 08-05-2013 the following is observed:

--1. At 2:03 P.M., the smoke barrier wall above the dropped ceiling by the pharmacy has a small hole through it.

The Facility Management Officer, the Electrician, and the HVAC Mechanic was present and acknowledge the finding.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1