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240 SOUTH MAIN STREET

WOLFEBORO, NH 03894

No Description Available

Tag No.: K0011

8.2.2.2, NFPA 101, LIFE SAFETY CODE
Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

8.2.3.2.4.2, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on record review, interview, and observation the facility failed to ensure that all fire barrier separations are properly maintained.

Findings include:

Record review of facility floor plans during tour on 8/1/12 and 8/2/12 revealed the locations of fire and smoke barriers in the facility.

Interview during tour on 8/1/12 between 2:30 p.m. and 3:30 p.m. with Staff B (Safety/Security Supervisor) and Staff C (Environmental Services Director) confirmed the first floor locations of the three hour fire barrier separations that separate the Medical Office Building from the Hospital.

Observation during tour on 8/1/12 between 2:30 p.m. and 3:30 p.m. with Staff B and Staff C revealed the following:

1. The three hour fire barrier located on the first floor at the cafeteria connector has at least one sprinkler pipe penetration that is unprotected and at least one pipe penetration that is partially protected with a surface coating of firestop material and partially unprotected.

2. The second three hour fire barrier located on the first floor has at least three metal sleeves that penetrate the barrier that are not protected on the interior of the sleeves.

Interview during tour on 8/1/12 with Staff B and Staff C confirmed the findings at the time of discovery.

No Description Available

Tag No.: K0012

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that applied fire resistive coatings are properly maintained.

Findings include:

Observation during tour between the afternoon of 8/1/12 and the morning of 8/2/12 with Staff B (Safety/Security Supervisor) and Staff C (Environmental Services Director) revealed the following:

1. Basement, elevator machine room C-002: The fire protective coating applied to the structural steel underneath the ceiling deck has been compromised due to the partial removal of the depth of the coating to accommodate a metal conduit.

2. First floor, H-100: The fire protective coating applied to the structural steel underneath the ceiling deck has been compromised due to the complete removal of the coating material on the bottom surface of the steel beam of approximately one foot in length.

Interview during tour on 8/1/12 and 8/2/12 with Staff B and Staff C at the time of discovery confirmed the findings.

No Description Available

Tag No.: K0029

18.3.2.1, NFPA 101, LIFE SAFETY CODE
Hazardous Areas: Any hazardous area shall be protected in accordance with Section 8.4...

8.4.1.1, NFPA 101, LIFE SAFETY CODE
Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

8.2.3.2.4.2, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation, record review, and interview the facility failed to ensure that hazardous area penetrations are properly protected.

Observation during tour on 8/1/12 between 1:30 p.m. and 3:30 p.m. with Staff B (Safety/Security Supervisor) and Staff C (Environmental Services Director) revealed the following:

1. Basement, electrical closet A-003: At least one penetration is not protected in the one hour fire barrier.

2. Basement, elevator machine room C-002: The opening around the I-beam is partially unprotected in the two hour fire barrier.

3. Basement, electrical room W-002: There are at least two unprotected penetrations in the two hour fire barrier.

4. First floor, cafeteria: The two hour fire barrier separation has at least one unprotected penetration and one unsealed membrane penetration.

Record review during tour on 8/1/12 of facility floor plans and interview with Staff B and Staff C at the time of discovery confirmed the fire barrier separation ratings and confirmed the findings.

No Description Available

Tag No.: K0047

18.2.10.1, NFPA 101, LIFE SAFETY CODE
Means of egress shall have signs in accordance with Section 7.10.

7.10.1.2, NFPA 101, LIFE SAFETY CODE
Exits: Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Based on observation and interview the facility failed to ensure that all means of egress have adequate exit signage.

Observation during tour on 8/1/12 at approximately 3:55 p.m. with Staff B (Safety/Security Supervisor) and Staff C (Environmental Services Director) revealed that the first floor lab has exit signage posted for only the primary means of egress.

Interview during tour on 8/1/12 with Staff B and Staff C revealed the location of a secondary means of egress and confirmed that it does not have exit signage posted.

No Description Available

Tag No.: K0104

18.3.7.3, NFPA 101, LIFE SAFETY CODE
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.

8.3.6.1, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on record review, interview, and observation the facility failed to ensure that all fire barrier separations are properly maintained.

Findings include:

Record review of facility floor plans during tour on 8/1/12 and 8/2/12 revealed the locations of fire and smoke barriers in the facility.

Interview during tour on 8/1/12 and 8/2/12 with Staff B (Safety/Security Supervisor) and Staff C (Environmental Services Director) confirmed the locations of smoke and fire barriers throughout the facility.

Observation during tour on 8/2/12 between 8:45 a.m. and 10:00 a.m. with Staff B and Staff C revealed the following:

1. First floor, emergency corridor smoke barrier in the area of door #1018A: At least one pipe penetration with a partial (incomplete) firestop seal.

2. Second floor, family waiting room smoke barrier: At least one insulated pipe penetrates the smoke barrier at an angle with a label documenting that firestop system #WL-5096 was used.

Record review of the firestop system during tour on 8/2/12 at the time of discovery with Staff B and Staff C for firestop system #WL-5096 revealed that the system used is not appropriate for angled insulated pipe penetrations.

Interview during tour on 8/2/12 with Staff B and Staff C at the time of discovery confirmed the findings.