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The facility failed to ensure the physical plant and patient care environment were safe from fire and in compliance with the 2000 edition of the National Fire Protection Association, Life Safety Code requirements applicable to the Critical Access Hospitals. The facility failed to ensure if a building had a common wall with a nonconforming building, the common wall is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition, failed to ensure the building construction type and height met the requirements of 19.1.6.2, and the exceptions addressed in the requirement with regard to an unprotected steel roof decking, failed to ensure stairways, between floors were enclosed with construction having a fire resistance rating of at least one hour, failed to ensure one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous area and when existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed. (C231)

Based on review of the facility schematic, facility observation and staff interview and confirmation, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The facility patient bed capacity is 25 with a census of 19 patients at the time of the survey.

Findings include:

On 01/05/15 through 01/08/15, between the 9:00 A.M. and 5:00 P.M., a Life Safety Code survey was conducted. Review of facility documentation, tour of the facility with facility staff and staff interviews were completed. The following findings with regard to the life safety code survey were noted:

K11, which addressed the facility failure to ensure that if a building had a common wall with a nonconforming building, the common wall is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition.

K12, which addressed the facility failure to ensure the building construction type and height met the requirements of 19.1.6.2, and the exceptions addressed in the requirement with regards to an unprotected steel roof decking.

K20, which addressed the facility failure to ensure that stairways, between floors were enclosed with construction having a fire resistance rating of at least one hour.

K29, which addressed the facility failure to ensure one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas.

K130, which addressed the facility failure to ensure that when existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.

Please see the life safety code report for more specific details.