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Based on review of the facility building schematic, observation of the facility and staff interview and confirmation, 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. 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 between 1:20 P.M. and 3:45 P.M., tour of the second floor was conducted with Staff S and T. Review of the facility schematics indicated the presence of a two hour fire rated wall located between the surgery waiting area, located in the health care occupancy and the administrators office, located in the business occupancy.

Observation above the ceiling tiles revealed the original ceiling. Interview of Staff T revealed the original plaster ceilings on each side of the wall was part of the fire rated barrier.

Observation above the ceiling tiles of the two hour fire rated separation revealed penetrations in the original plaster lathe ceiling. Located above the ceiling tiles in the surgical waiting area, was two penetrations. One penetration was approximately two feet in diameter and a second penetration was approximately four inches in diameter. Wiring and flex cable extended through the open areas.

Observation above the ceiling tiles in the administrator's office revealed a penetration approximately 12 inches in diameter in the original plaster ceiling.

Interview of Staff T revealed the original plaster ceilings on each side of the wall provided the fire rated barrier. The fire rated wall between the two occupancies did not extend to the roof decking.

Based on review of the facility building information, observation of the facility and staff interview and confirmation, the facility 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 regards to an unprotected steel roof decking. 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 between 1:20 P.M. and 3:45 P.M., tour of the second floor was conducted with Staff S and T. Review of building information indicated the two story facility was construction type I(332). The second floor of the facility was not provided automatic sprinkler protection.

During observation above the ceiling tiles of the facility fire rated barrier wall between the health care occupancies and the business occupancy, unprotected steel roof decking was observed.

Interview of Staff S and T, acknowledged they were aware the steel roof decking was unprotected and had future plans to address the problem. Staff stated the original construction of the building had a plaster lathe ceiling which provided at least a one hour fire rating. The plaster ceiling was removed, in the corridor portion of the second floor when the dropped ceiling tiles were added. Staff further confirmed the facility operating rooms, sleep clinic and same day surgery was located on the second floor of the facility.

Based on review of the facility building schematic, observation of the facility and staff interview and confirmation, the facility failed to ensure stairways, between floors were enclosed with construction having a fire resistance rating of at least one hour. 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 between 1:20 P.M. and 3:45 P.M., tour of the second floor was conducted with Staff S and T. Review of the facility schematics indicated the presence of stairways enclosed with one hour fire rated construction.

1. Observation of the south hall stairway, located at the surgical waiting area, revealed the stairway had dropped ceiling tiles. Staff T confirmed the ceiling tiles had no fire resistance rating. Observation above the ceiling tiles revealed the original plaster lathe ceiling. Penetrations were noted surrounding at least four screws that were drilled into the plaster to hang the ceiling tiles. Staff T confirmed the original construction of the building had a plaster lathe ceiling which provided at least a one hour fire rating.

2. Observation above the ceiling tiles of the center stairway, located near the same day surgery nursing desk, revealed penetrations surrounding at least two screws placed in the original ceiling plaster.

Observation of the first floor was conducted on 01/06/15 between 11:23 A.M. and 4:00 P.M. with Staff S and T.

3. Observation of the first floor level of the south hall stairway, located near the laboratory, revealed a penetration in the one hour fire rated wall of the stair. Observation of the enclosure from the interior of a former mechanical space (room 150 F on the schematic) revealed a pipe approximately two inches in diameter that penetrated the one hour wall of the stairway.

4. Observation of the exit discharge door for the stairway located at the front entrance of the facility had no identifiable fire resistance rating on the door.

Staff S and T, present on the tour, confirmed the observations.

Based on review of the facility schematic, observation of the facility and staff interview and confirmation, the facility 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 areas. 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 between 1:20 P.M. and 3:45 P.M., tour of the second floor was conducted with Staff S and T. Observation of the second floor revealed there was no automatic sprinkler protection. Staff S and T confirmed the observation. Staff T further revealed that original ceiling construction of plaster lather provided one hour fire resistance. The following hazardous storage areas were noted to have penetrations in the one hour fire rated construction:

1. Observation of the hazardous storage room located near the nursing station for surgical patient's and adjacent to the stairway, revealed a one and one half inch open conduit pipe noted to penetrate through the exterior of the one hour fire rated wall on the main corridor side of the wall.

2. Observation of a storage room, room 209, revealed a sealed copper pipe approximately 12 inches from the floor. The space surrounding the pipe was not sealed. Observed at the upper corner of the room, near the ceiling, revealed a data wire which extended through the ceiling. The space surrounding the wire was not sealed.

3. Observation of a large surgical supply room, revealed a solid plaster lathe ceiling for the room. Two access panels, approximately 12 inches square, were cut in the ceiling. Observation of the access panels revealed they were painted wood, approximately one fourth inch in diameter. Staff T confirmed the painted wood panels did not maintain a one hour fire resistance rating for the ceiling.

4. Observation above the ceiling tiles from room 235 of a one hour fire rated wall for a hazardous area, revealed an area at least 18 inches in length that was not sealed. Light could be seen through the opening from the hazardous storage area.

5. Observation of electrical panel rooms, located near the elevator, revealed unsealed spaces surrounding four silver conduit, and a single conduit.

6. Observation of room 207, noted to be a hazardous storage area, was observed on 01/06/15 at approximately 2:16 PM. The room, located across from the nursing station for surgery patients was noted to have a suspended ceiling. Observation above the ceiling tiles revealed the hangers for the ceiling which penetrated the plaster lathe ceiling above it. The plaster and lathe ceiling was considered to be part of the one hour fire wall around the room.

Tour of the first floor was conducted with Staff S and T on 01/06/15 between 11:23 A.M. and 4:00 P.M. Observation and confirmation by staff revealed the first floor of the facility was provided automatic sprinkler protection. Review of the facility schematic identified one hour fire rated construction was also present for specific hazardous areas The following observations were noted in hazardous storage areas on the first floor;

7. Review of the facility schematic revealed there was a one hour fire rated separation surrounding a large medical supply room. Observation, above the drop ceiling tiles, above the lockers in the men's locker room of the one hour fire rated wall, revealed it was not finished and was unsealed in multiple areas. The wall was not sealed across the framing studs and the area was open to the interior of the fire wall. Staff S and T confirmed the observation.

Observation above the ceiling tiles of the fire rated wall from inside room 111 A, located inside the larger store room, revealed two penetrations, approximately four inches in diameter. One penetration was noted to have two small data cables passing through it.


8. Observation from the maintenance hallway of the fire rated wall which separated the mechanical room, revealed open space surrounding two conduits protruding from the wall. Also noted was unsealed space surrounding a pipe in the wall.

All observations were confirmed by Staff S and T, present for the tour.

NFPA 13, Standard for Installation of Sprinklers
Chapter 5
5-3.1.5.2
When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.

Based on facility observation and staff interview and confirmation, the facility failed 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. The facility patient bed capacity is 25 with a census of 19 patients at the time of the survey.

Findings include:

Tour of the first floor was conducted with Staff S and T on 01/06/15 between 11:23 A.M. and 4:00 P.M. During the tour, it was observed that in the Pharmacy Directors office, room 109, the sprinkler heads were of a different style then what was used in the main pharmacy area. Staff T confirmed the sprinkler heads were of an older style and were a normal response type head. The sprinkler heads used in the main pharmacy area were on the same sprinkler supply line but were a quick response sprinkler head. The pharmacy and the pharmacist's office are in the same smoke compartment of the first floor.

Interview of Staff S and T on 01/08/14 at 1:25 P.M. regarding installation of the sprinkler system for the pharmacy area and the pharmacist's office revealed the sprinkler system was installed in the pharmacy in 1997. At that time, there was no office for the pharmacist. The room, currently used as the pharmacist office was a dietary office. Some time later, length of time unknown, the dietary office became the office for the pharmacist. At that time a door was created from the pharmacy to the pharmacist's office.

Staff T confirmed the sprinkler heads were not changed from the older style heads in the former dietary office to the quick response heads when the pharmacist office was created.

Based on review of the facility building schematic, observation of the facility and staff interview and confirmation, 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. 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 between 1:20 P.M. and 3:45 P.M., tour of the second floor was conducted with Staff S and T. Review of the facility schematics indicated the presence of a two hour fire rated wall located between the surgery waiting area, located in the health care occupancy and the administrators office, located in the business occupancy.

Observation above the ceiling tiles revealed the original ceiling. Interview of Staff T revealed the original plaster ceilings on each side of the wall was part of the fire rated barrier.

Observation above the ceiling tiles of the two hour fire rated separation revealed penetrations in the original plaster lathe ceiling. Located above the ceiling tiles in the surgical waiting area, was two penetrations. One penetration was approximately two feet in diameter and a second penetration was approximately four inches in diameter. Wiring and flex cable extended through the open areas.

Observation above the ceiling tiles in the administrator's office revealed a penetration approximately 12 inches in diameter in the original plaster ceiling.

Interview of Staff T revealed the original plaster ceilings on each side of the wall provided the fire rated barrier. The fire rated wall between the two occupancies did not extend to the roof decking.

Based on review of the facility building information, observation of the facility and staff interview and confirmation, the facility 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 regards to an unprotected steel roof decking. 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 between 1:20 P.M. and 3:45 P.M., tour of the second floor was conducted with Staff S and T. Review of building information indicated the two story facility was construction type I(332). The second floor of the facility was not provided automatic sprinkler protection.

During observation above the ceiling tiles of the facility fire rated barrier wall between the health care occupancies and the business occupancy, unprotected steel roof decking was observed.

Interview of Staff S and T, acknowledged they were aware the steel roof decking was unprotected and had future plans to address the problem. Staff stated the original construction of the building had a plaster lathe ceiling which provided at least a one hour fire rating. The plaster ceiling was removed, in the corridor portion of the second floor when the dropped ceiling tiles were added. Staff further confirmed the facility operating rooms, sleep clinic and same day surgery was located on the second floor of the facility.

Based on review of the facility building schematic, observation of the facility and staff interview and confirmation, the facility failed to ensure stairways, between floors were enclosed with construction having a fire resistance rating of at least one hour. 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 between 1:20 P.M. and 3:45 P.M., tour of the second floor was conducted with Staff S and T. Review of the facility schematics indicated the presence of stairways enclosed with one hour fire rated construction.

1. Observation of the south hall stairway, located at the surgical waiting area, revealed the stairway had dropped ceiling tiles. Staff T confirmed the ceiling tiles had no fire resistance rating. Observation above the ceiling tiles revealed the original plaster lathe ceiling. Penetrations were noted surrounding at least four screws that were drilled into the plaster to hang the ceiling tiles. Staff T confirmed the original construction of the building had a plaster lathe ceiling which provided at least a one hour fire rating.

2. Observation above the ceiling tiles of the center stairway, located near the same day surgery nursing desk, revealed penetrations surrounding at least two screws placed in the original ceiling plaster.

Observation of the first floor was conducted on 01/06/15 between 11:23 A.M. and 4:00 P.M. with Staff S and T.

3. Observation of the first floor level of the south hall stairway, located near the laboratory, revealed a penetration in the one hour fire rated wall of the stair. Observation of the enclosure from the interior of a former mechanical space (room 150 F on the schematic) revealed a pipe approximately two inches in diameter that penetrated the one hour wall of the stairway.

4. Observation of the exit discharge door for the stairway located at the front entrance of the facility had no identifiable fire resistance rating on the door.

Staff S and T, present on the tour, confirmed the observations.

Based on review of the facility schematic, observation of the facility and staff interview and confirmation, the facility 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 areas. 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 between 1:20 P.M. and 3:45 P.M., tour of the second floor was conducted with Staff S and T. Observation of the second floor revealed there was no automatic sprinkler protection. Staff S and T confirmed the observation. Staff T further revealed that original ceiling construction of plaster lather provided one hour fire resistance. The following hazardous storage areas were noted to have penetrations in the one hour fire rated construction:

1. Observation of the hazardous storage room located near the nursing station for surgical patient's and adjacent to the stairway, revealed a one and one half inch open conduit pipe noted to penetrate through the exterior of the one hour fire rated wall on the main corridor side of the wall.

2. Observation of a storage room, room 209, revealed a sealed copper pipe approximately 12 inches from the floor. The space surrounding the pipe was not sealed. Observed at the upper corner of the room, near the ceiling, revealed a data wire which extended through the ceiling. The space surrounding the wire was not sealed.

3. Observation of a large surgical supply room, revealed a solid plaster lathe ceiling for the room. Two access panels, approximately 12 inches square, were cut in the ceiling. Observation of the access panels revealed they were painted wood, approximately one fourth inch in diameter. Staff T confirmed the painted wood panels did not maintain a one hour fire resistance rating for the ceiling.

4. Observation above the ceiling tiles from room 235 of a one hour fire rated wall for a hazardous area, revealed an area at least 18 inches in length that was not sealed. Light could be seen through the opening from the hazardous storage area.

5. Observation of electrical panel rooms, located near the elevator, revealed unsealed spaces surrounding four silver conduit, and a single conduit.

6. Observation of room 207, noted to be a hazardous storage area, was observed on 01/06/15 at approximately 2:16 PM. The room, located across from the nursing station for surgery patients was noted to have a suspended ceiling. Observation above the ceiling tiles revealed the hangers for the ceiling which penetrated the plaster lathe ceiling above it. The plaster and lathe ceiling was considered to be part of the one hour fire wall around the room.

Tour of the first floor was conducted with Staff S and T on 01/06/15 between 11:23 A.M. and 4:00 P.M. Observation and confirmation by staff revealed the first floor of the facility was provided automatic sprinkler protection. Review of the facility schematic identified one hour fire rated construction was also present for specific hazardous areas The following observations were noted in hazardous storage areas on the first floor;

7. Review of the facility schematic revealed there was a one hour fire rated separation surrounding a large medical supply room. Observation, above the drop ceiling tiles, above the lockers in the men's locker room of the one hour fire rated wall, revealed it was not finished and was unsealed in multiple areas. The wall was not sealed across the framing studs and the area was open to the interior of the fire wall. Staff S and T confirmed the observation.

Observation above the ceiling tiles of the fire rated wall from inside room 111 A, located inside the larger store room, revealed two penetrations, approximately four inches in diameter. One penetration was noted to have two small data cables passing through it.


8. Observation from the maintenance hallway of the fire rated wall which separated the mechanical room, revealed open space surrounding two conduits protruding from the wall. Also noted was unsealed space surrounding a pipe in the wall.

All observations were confirmed by Staff S and T, present for the tour.

NFPA 13, Standard for Installation of Sprinklers
Chapter 5
5-3.1.5.2
When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.

Based on facility observation and staff interview and confirmation, the facility failed 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. The facility patient bed capacity is 25 with a census of 19 patients at the time of the survey.

Findings include:

Tour of the first floor was conducted with Staff S and T on 01/06/15 between 11:23 A.M. and 4:00 P.M. During the tour, it was observed that in the Pharmacy Directors office, room 109, the sprinkler heads were of a different style then what was used in the main pharmacy area. Staff T confirmed the sprinkler heads were of an older style and were a normal response type head. The sprinkler heads used in the main pharmacy area were on the same sprinkler supply line but were a quick response sprinkler head. The pharmacy and the pharmacist's office are in the same smoke compartment of the first floor.

Interview of Staff S and T on 01/08/14 at 1:25 P.M. regarding installation of the sprinkler system for the pharmacy area and the pharmacist's office revealed the sprinkler system was installed in the pharmacy in 1997. At that time, there was no office for the pharmacist. The room, currently used as the pharmacist office was a dietary office. Some time later, length of time unknown, the dietary office became the office for the pharmacist. At that time a door was created from the pharmacy to the pharmacist's office.

Staff T confirmed the sprinkler heads were not changed from the older style heads in the former dietary office to the quick response heads when the pharmacist office was created.