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Based on observation, the facility failed to close penetrations and openings to ensure the fire and smoke resistive properties of the structure were maintained. Failure to seal penetrations and openings would allow fire, smoke and dangerous gases to communicate between compartments reducing evacuation capabilities. This deficient practice affected all patients, staff and visitors on the date of the survey. The facility is licensed for 23 hospital beds and had a census of 8 on the day of the survey.

Findings include:

During the facility tour conducted on December 3, 2015 from 10:00 AM to 12:30 PM, observation of the facility found the following unsealed penetrations:

1) In the Boiler room, inspection of the ceiling revealed an unsealed hole approximately two foot by two foot in size exposing the floor above, along with two (2) open holes approximately three inches in diameter exposing the floor above.

2) In the basement "Pop" storage area, inspection of the ceiling revealed an unsealed two inch diameter hole.

3) In the IT closet abutting the Oxygen storage area, inspection of the floor revealed two (2) unsealed holes approximately two inches in diameter.

Actual NFPA standard:

19.1.6.2
Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Exception%: Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:
(a) The roof covering meets Class C requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a nonc

Based on observation and operational testing, the facility failed to ensure corridor doors were maintained to resist the passage of smoke. Failure to provide corridor doors which resist the passage of smoke would allow products of combustion to enter corridors and hinder egress capabilities. This deficient practice affected all patients, staff and visitors on the date of the survey. The facility is licensed for 23 hospital beds and had a census of 8 on the day of the survey.

Findings include:

During the facility tour conducted on December 3, 2015 from 10:00 AM to 12:30 PM, observation and operational testing of the double doors from the corridor into the Emergency room suite revealed the upper half of the doors had a gap of approximately 1/4".

Actual NFPA standard:

19.3.6.3 Corridor Doors.

19.3.6.3.1%
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist