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Where separated occupancies are provided, each part of the building comprising a distinct occupancy, as described
in this chapter, shall be completely separated from other occupancies by fire-resistive assemblies, as specified in 6.1.14.4.2, 6.1.14.4.3, Table 6.1.14.4.1(a), and Table 6.1.14.4.1(b), unless separation is provided by approved existing separations.

Based on visual observation, the facility failed to assure proper separation was maintained between distinct occupancies in accordance with NFPA 101 6.1.14.4.1. The 2 hour separation is required to be maintained between the occupancies. The deficient practice has the potential to affect 35 of 35 residents.

Findings:
During the facility tour on 11/4/2020, between the hours of 8:00a-4:30p observation revealed the 90 minute fire doors had been removed between the gym (assembly occupancy) and classrooms (education occupancy).

Interview with the Administrator revealed the facility was not aware the doors had been removed from the 2 hour barrier.

Based on visual observation and record review the facility failed to assure that semi-annual inspections and routine cleanings were conducted by a licensed contractor on the commercial hood/suppression system. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system. The deficient practice had the potential to affect 35 of 35 residents.

Findings:

During the facility tour and record review on 11/4/2020, between the hours of 8:00a-4:30p observation revealed the semi-annual inspection of the kitchen suppression system was not conducted. The last inspection was completed on 1/9/2020.

Interview with the Administrator revealed the facility was not aware the semi-annual inspection was not conducted on the hood suppression system.

* Waiver Granted

Based on visual observation the facility failed to provide corridor doors that were not closing and latching in the frame. When the doors latch a smoke resistive seal is formed to protect the room ' s occupants. The deficient practice had the potential to affect 35 of 35 residents.


Findings:

During the facility tour on 11/4/2020, between the hours of 8:00a-4:30p observation revealed the doors to rooms 028 and 002 had a gap at the top of the door. Observation also revealed the doors to rooms 017 and 004 did not latch in the frame.

Interview with the Administrator revealed the facility was not aware of the door to Room 028 and 002 did not create a seal, when closed, to prevent the transfer of smoke nor door to room 017 aand 004 did not latching in the frame.

Doors in smoke barriers are 1 ¾ inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door openings provides a minimum clear width of 32 inch for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9.

Based on visual observation the facility failed to assure that the smoke barrier doors in the facility properly protected the smoke compartment. The smoke barrier doors restrict the movement of smoke from one compartment to another. The deficient practice had the potential to affect 35 of 35 residents.

Findings:

During the facility tour on 11/4/2020, between the hours of 8:00a-4:30p observation revealed the closures were removed from the barrier doors in A and B dorms.

Interview with the Administrator revealed the facility was not aware the closures were removed from the cross corridor doors in A and B dorms so the doors were not self-closing.

Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking.
6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2 (NFPA 99)

Based on visual observation, the facility failed to assure electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking, in accordance with NFPA 99 6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2. The electrical receptacles or cover plates supplied from the life safety and critical branches are required to have a distinctive color or marking. The deficient practice has the potential to affect 35 of 35 residents.

Findings:

During the facility tour on 11/4/2020, between the hours of 8:00a-4:30p observation revealed the electrical receptacles or cover plates supplied from the life safety and critical branches were not a distinctive color or marking.

Interview with the revealed the facility was not aware the receptacle or cover plates that supply the life safety branch were not distinct in color or marking.

K920 Electrical Equipment - Power Cords and Extension Cords

Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for mom-PCREE (e.g. personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3 (D) (NFPA 70), TIA 12.5.

Based on visual observation, the facility failed to assure that the power strips used in patient care areas and non patient care areas are installed correctly. Facility failed to assure the use of extension cords are for temporary purpose only and are removed immediately when project is complete. The deficient practice had the potential to affect 35 of 35 residents.

Findings:

During the facility tour on 11/4/2020, between the hours of 8:00a-4:30p observation revealed power strips daisy chained together. Observation also revealed the use of extension cords for perment wiring in the Annex.

Interview with the Administrator revealed the facility was not aware of the power strips daisy chained together or the use of extension cords for permanent wiring.