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Tag No.: K0025
NFPA (National Fire Protection Association) 101 Life Safety Code 2000 Edition
Chapter 19 EXISTING HEALTH CARE OCCUPANCIES
19.3 Protection
19.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
Chapter 8 FEATURES OF FIRE PROTECTION
8.3 Smoke Barriers
8.3.2
To ensure that a smoke barrier is continuous, it is necessary to seal completely all openings where the smoke barrier abuts other smoke barriers, fire barriers, exterior walls, the floor below, and the floor or ceiling above. It is not the intent to prohibit a smoke barrier from stopping at a fire barrier if the fire barrier meets the requirements of a smoke barrier (that is, the fire barrier is a combination smoke barrier/fire barrier).
This Standard is not met as evidenced by:
Based on observation and staff interview it was determined the facility failed to maintain smoke barrier walls to provide at least one half hour fire resistance rating.
Findings include:
1. On 11/03/15 at approximately 10:00 a.m., an inspection of the smoke barrier above the dropped ceiling near the Double Elevators on the third floor, West End of the Building, revealed there were two (2) small holes going into the elevator shaft that were not sealed.
2. On 11/03/15 at approximately 10:30 a.m., an inspection of the smoke barrier above the dropped ceiling at the smoke doors revealed there were two (2) holes beside duct work that was not sealed.
3. On 11/03/15 at approximately 10:35 a.m., an inspection of the smoke barrier above the dropped ceiling near the B and C East corridor revealed there was a two (2) inch hole with communication wires running through the smoke barrier wall that was not sealed.
4. The above findings were discussed with the facility maintenance director on 11/03/15 at approximately 10:45 a.m. who agreed there were openings in the smoke barrier walls.
Tag No.: K0052
NFPA (National Fire Protection Association) 72 National Fire Alarm Code 1999 Edition
Chapter 7 Inspection, Testing, and Maintenance
7-3 Inspection and Testing Frequency.
7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
This Standard is not met as evidenced by:
Based on observation and staff interview it was determined the facility failed to maintain the fire alarm system in accordance with NFPA 72.
Findings include:
1. On 11/02/15 at approximately 1:20 p.m., a review of the fire alarm testing records for the fire alarm system revealed there was no documentation or record of a sensitivity test for the smoke detectors.
2. The above findings were discussed with the facility maintenance director on 11/02/15 at approximately 1:25 p.m. and agreed the fire alarm inspection report lacked documentation that all components were tested, including sensitivity testing of the smoke detectors.
Tag No.: K0062
NFPA (National Fire Protection Association) 25 - Standard for the Inspection, Testing, and Maintenance of Water-based Protection Systems
6-1.1.5 Sprinkler piping on hangers shall not be used to support nosystem components.
A-6-1.1.5 The rules covering the hanging of sprinkler piping take into consideration the weight of water-filled pipe plus a safety factor. No allowance has been made for hanging of nonsystem components from sprinkler piping.
This Standard is not met as evidenced by:
Based on observation and staff interview it was determined the facility failed to maintain the sprinkler piping in accordance with NFPA 25.
Findings include:
1. On 11/03/15 at approximately 11:50 am, the sprinkler piping above the dropped ceiling throughout the facility was found to have cables draped over them.
2. The above findings were discussed with the facility maintenance director on 11/03/15 at approximately 11:50 am who agreed the facility sprinkler system needed to be corrected.