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Based on observation and staff interview, the facility failed to provide corridor openings that would resist the passage of smoke in accordance to NFPA 101 Section 19.3.6.3.1. This deficient practice could affect the patients in one of nine smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On September 14th, 2015 at 1:25 pm (on the second floor) while on tour with Staff 'M', it was observed that the paired doors into the Corridor from the four (4) step-down patient rooms was equipped with astragals at the meeting edge of the doors to resist the passage of smoke. These astragals were not adjusted to prevent the movement of smoke through these paired leaf openings.

Based on observation and staff interviews, the facility failed to provide and maintain openings in smoke barriers that resist the passage of smoke in accordance to NFPA 101 Section 19.3.7.5. This deficient practice could affect the patients in two of four smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On September 16th, 2015 at 3:55 pm (within the first floor) while on tour with Staff 'M', it was observed that the door into the Corridor from Vitals #1-127 was equipped with an astragal that was missing the smoke seal. This paired leaf opening did not prevent the movement of smoke through the smoke barrier.

2. On September 16th, 2015 at 3:57 pm (within the first floor) while on tour with Staff 'M', it was observed that the door into the Corridor from Vitals #1-149 was equipped with an astragal that was missing the smoke seal. This paired leaf opening did not prevent the movement of smoke through the smoke barrier.

Based on observation and a staff interview, the facility failed to provide a one-hour rated enclosure with 45-minute rated doors around a hazardous area per NFPA 101 [2000 Ed] Section 19.3.2.1. This deficient practice could affect the patients in one of nine smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On September 14th, 2015 at 3:20 pm (within the first floor) while on tour with Staff 'M', it was observed that an office was changed to a storage space. This space, greater than 100 square feet and used to store combustibles, is located within an I-2 facility. The door was not a 45-minute door with a closer, walls surrounding this space were not taped and mudded to a one-hour fire barrier standard and the penetrations through these walls were not fire-caulked. This room does not meet Section 19.3.2.1 "Any hazardous area(s) shall be safeguarded by a fire barrier having a 1-hour resistance rating. Hazardous areas shall include...the following: (7) Rooms larger than 50 square feet...for storage of combustible supplies..."

Based on observations and staff interviews, the facility failed to provide and maintain a fire alarm system with approved components and devices installed according to NFPA 72 Section 19.3.4 in all 'common areas' of this building. This deficient practice could affect the patients in one of the nine smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On September 14th, 2015 at 3:40 pm (within the first floor) while on tour with Staff 'M', it was observed that the clean equipment room #1-148 has changed function to a two-person office. NFPA 72 requires that all 'common areas' be equipped with a visible appliance. No fire alarm strobe was installed within office #1-148, which is now a 'common area' of this building.

2. On September 14th, 2015 at 3:45pm (within the first floor) while on tour with Staff 'M' , it was observed that the clean equipment room #1-122 has changed function to a two-person office. NFPA 72 requires that all 'common areas' be equipped with a visible appliance. No fire alarm strobe was installed within office #1-148, which is now a 'common area' of this building.

Based on observation and staff interviews, the facility failed to provide egress through a door that met the following Sections 19.2.2.2.1, 7.2.1 and 7.2.1.5.4 This deficient practice could affect the patients in one of the nine smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On September 14th, 2015 at 12:30 pm (within the first floor) while on tour with Staff 'M', it was observed that the door from the Unisex Toilet located off the Main waiting area was equipped with a deadbolt and a lever. To egress this space the occupant must utilize two operations to egress the space. This does not meet Section 7.2.1.5.4 which states; "...Doors shall be operable with not more than one releasing operation."

Based on observation and staff interview, the facility failed to provide corridor openings that would resist the passage of smoke in accordance to NFPA 101 Section 19.3.6.3.1. This deficient practice could affect the patients in one of nine smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On September 14th, 2015 at 1:25 pm (on the second floor) while on tour with Staff 'M', it was observed that the paired doors into the Corridor from the four (4) step-down patient rooms was equipped with astragals at the meeting edge of the doors to resist the passage of smoke. These astragals were not adjusted to prevent the movement of smoke through these paired leaf openings.

Based on observation and staff interviews, the facility failed to provide and maintain openings in smoke barriers that resist the passage of smoke in accordance to NFPA 101 Section 19.3.7.5. This deficient practice could affect the patients in two of four smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On September 16th, 2015 at 3:55 pm (within the first floor) while on tour with Staff 'M', it was observed that the door into the Corridor from Vitals #1-127 was equipped with an astragal that was missing the smoke seal. This paired leaf opening did not prevent the movement of smoke through the smoke barrier.

2. On September 16th, 2015 at 3:57 pm (within the first floor) while on tour with Staff 'M', it was observed that the door into the Corridor from Vitals #1-149 was equipped with an astragal that was missing the smoke seal. This paired leaf opening did not prevent the movement of smoke through the smoke barrier.

Based on observation and a staff interview, the facility failed to provide a one-hour rated enclosure with 45-minute rated doors around a hazardous area per NFPA 101 [2000 Ed] Section 19.3.2.1. This deficient practice could affect the patients in one of nine smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On September 14th, 2015 at 3:20 pm (within the first floor) while on tour with Staff 'M', it was observed that an office was changed to a storage space. This space, greater than 100 square feet and used to store combustibles, is located within an I-2 facility. The door was not a 45-minute door with a closer, walls surrounding this space were not taped and mudded to a one-hour fire barrier standard and the penetrations through these walls were not fire-caulked. This room does not meet Section 19.3.2.1 "Any hazardous area(s) shall be safeguarded by a fire barrier having a 1-hour resistance rating. Hazardous areas shall include...the following: (7) Rooms larger than 50 square feet...for storage of combustible supplies..."

Based on observations and staff interviews, the facility failed to provide and maintain a fire alarm system with approved components and devices installed according to NFPA 72 Section 19.3.4 in all 'common areas' of this building. This deficient practice could affect the patients in one of the nine smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On September 14th, 2015 at 3:40 pm (within the first floor) while on tour with Staff 'M', it was observed that the clean equipment room #1-148 has changed function to a two-person office. NFPA 72 requires that all 'common areas' be equipped with a visible appliance. No fire alarm strobe was installed within office #1-148, which is now a 'common area' of this building.

2. On September 14th, 2015 at 3:45pm (within the first floor) while on tour with Staff 'M' , it was observed that the clean equipment room #1-122 has changed function to a two-person office. NFPA 72 requires that all 'common areas' be equipped with a visible appliance. No fire alarm strobe was installed within office #1-148, which is now a 'common area' of this building.

Based on observation and staff interviews, the facility failed to provide egress through a door that met the following Sections 19.2.2.2.1, 7.2.1 and 7.2.1.5.4 This deficient practice could affect the patients in one of the nine smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On September 14th, 2015 at 12:30 pm (within the first floor) while on tour with Staff 'M', it was observed that the door from the Unisex Toilet located off the Main waiting area was equipped with a deadbolt and a lever. To egress this space the occupant must utilize two operations to egress the space. This does not meet Section 7.2.1.5.4 which states; "...Doors shall be operable with not more than one releasing operation."