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Based on observation and interview, the facility failed to maintain the integrity of corridor walls in accordance with 18.3.6.1 for a separation between a hazardous area mechanical room and the adjacent corridor which serves as a protected egress to a designated north exit. The facility census was four.

Findings included:

1. Observations on 04/04/12 at 1:28 PM showed one half inch annular spaces around three separate penetrations of one inch metal electrical conduit in the wall between Materials Management and the Mechanical Room. Another one half-inch annular space surrounded a conduit that penetrated the south wall between the Mechanical Room and Medical Records.

2. Observation on 04/05/12 at 11:01 AM showed a two inch annular space around two 10-inch insulated pipes that penetrated the wall between the service corridor which serves as egress to a designated fire exit and a mechanical room containing heating, ventilation, air conditioning and water heating equipment.

During an interview on 04/04/12 at 11:05 AM, Staff W acknowledged the observation and stated that maintenance workers had checked and sealed barrier walls but there were probably some that they had missed. He stated he did not have a preventive maintenance policy for checking behind contractors or installers doing post-construction work above the suspended tile ceiling.

Based on observation and interview, the facility failed to ensure the integrity of smoke and fire barriers in accordance with 8.3 and 18.3.7.3 to maintain the required minimum one hour fire resistance rating above doors in two (C-02 and C-13) of six pair of fire doors that separate the facility into three of three major fire zones. This deficient practice potentially enables the spread of smoke and fire gases to penetrate into separate fire zones and affect visitors, staff, inpatients and outpatient census. The inpatient census was four.

Findings included:

1. Observations on 04/04/12 at 10:40 AM of the fire wall above the ceiling on the south side of a pair of fire separation doors identified by Maintenance as C-02 showed the following:
-One half inch-wide annular spaces around two metal conduits and one flexible cable;
-One inch high by two inch wide space at the bottom of a supply duct;
-Three inch high by 12 inch wide wire tray with communication (computer and telephone) cables that penetrated the wall.

2. Observations on 04/04/12 at 10:45 AM of the fire wall above the ceiling on the north side of the same set of fire doors showed wires from the electric door controls penetrated into an unsealed hole that measured one half inch high by two inches wide.

3. Observations on 04/05/12 at 10:55 AM of the fire wall above the ceiling on the north side of a pair of fire separation doors identified as C-13 showed the following:
-Two, half-inch electrical conduits with one half inch and one quarter inch unsealed annular spaces around them;

4. Observations on 04/05/12 at 10:56 AM of the fire wall above the ceiling on the south side of a pair of fire separation doors identified as C-13 showed the following:
-A one inch square hole in the fire wall for a one half-inch diameter flex conduit.

During an interview on 04/05/12 at 9:20 AM, Staff G acknowledged the observation and stated that workers had checked and sealed barrier walls but there were probably some that they had missed. He stated he did not have a preventive maintenance policy for checking behind contractors or installers doing post-construction work above the suspended tile ceiling.

Based on observations and interview, the facility failed to ensure a minimum 20-minute fire protection rating for six of six pair of fire doors separating the three major smoke zones designated by the facility (walls constructed and finished to the roof deck to provide a fire barrier and resist the passage of smoke) in accordance with 18.3.7.8 (2000 "new" construction) of the Life Safety Code requirements. The deficient practice affects all staff, visitors, outpatients and inpatients throughout the facility's total of eight smoke compartments in the one-story structure. The facility census was four patients.

Findings included:

1. Observations on 04/04/12 at 1:04 P.M. through 11/05/12 at 2:00 PM showed gaps of up to one-quarter inch between a set of self-closing fire doors and no astragals (molding attached to one of two leafs of a double door that creates a smoke tight barrier) to prevent the spread of smoke from one compartment to another at the following six locations:
-Corridor between the kitchen and mechanical room;
-Corridor between the cafeteria and outpatient clinics;
-Corridor between the outpatient clinics and public toilet rooms;
-Corridor between Pharmacy and Radiology;
-Corridor between Pharmacy and Surgery suites (East of Pharmacy);
-Corridor between Patient room 114 and the back wall of Surgery.

During an interview on 04/05/12 at 9:20 AM, Staff G acknowledged the observation and stated that he was not aware of this regulation for new construction. He stated that he had been working with the installers to ensure gaps between each pair of doors in the closed position were maintained at one eighth inch or less.