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Based on observation and interview, the facility failed to ensure that there was no impediments to closing the corridor doors. This was evidenced by 13 doors on the B Unit and 3 doors on the W-1 Unit that failed to self close and latch. This could result in a delay to contain fire or smoke during a fire. This affected three of three smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3 Corridor Doors.
19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
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: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.

19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour with the Fire Chief, and the Chief of Plant Operations on 10/28/15, the corridor doors were observed.

B Unit
1. At 1:25 p.m., door 233A was equipped with a door closer that failed to self-close and latch.

2. At 1:28 p.m., door 244A was equipped with a door closer that failed to self-close and latch.

3. At 1:29 p.m., door 232 was equipped with a door closer that failed to self-close and latch.

4. At 1:33 p.m., door 232A was equipped with a door closer that failed to self-close and latch.

5. At 1:35 p.m., door 228 was equipped with a door closer that failed to self-close and latch.

6. At 1:37 p.m., door 238 was equipped with a door closer that failed to self-close and latch.

7. At 1:40 p.m., door 226 was equipped with a door closer that failed to self-close and latch.

8. At 1:42 p.m., door 224 was equipped with a door closer that failed to self-close and latch.

9. At 1:44 p.m., door 229 was equipped with a door closer with the latch mechanism missing.

10. At 1:48 p.m., door 224 was equipped with a door closer that failed to self-close and latch

11. At 1:52 p.m., door 219 was equipped with a door closer that failed to self-close and latch.

12. At 1:53 p.m., door 216 was equipped with a door closer but the latch mechanism was missing.

13. At 1:54 p.m., door 233 was equipped with a door closer that failed to self-close and latch.

W-1 Unit
14. At 1:57 p.m., the washer and dryer room door failed to close and latch.

15. At 2:01 p.m., the door to Room 1154 was equipped with a door closer that failed to self-close and latch.

16. At 2:02 p.m., the door to Room 1155 was equipped with a door closer that failed to self-close and latch.

17. At 2:03 p.m., during interview, Nurse Staff 1 stated that the corridor doors suffered repeat failures since the last repair. Nurse Staff 1 pointed to the work order copies that were placed on the doors for Rooms 1154 and 1155 a few days earlier.

Based on observation and interview, the facility failed to ensure that stairwell openings maintained a safe path of escape with fire protection. This was evidenced by stairwell doors that failed to close and latch in Unit B on the second floor. This could result in the spread of fire or smoke in the event of a fire. This affected two of three smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
Exception No. 1: Unprotected vertical openings in accordance with 8.2.5.8 shall be permitted.
Exception No. 2: Exception No. 1 to 8.2.5.6(1) shall not apply to patient sleeping and treatment rooms.
Exception No. 3: Multilevel patient sleeping areas in psychiatric facilities shall be permitted without enclosure protection between levels, provided that all the following conditions are met:
(a) The entire normally occupied area, including all communicating floor levels, is sufficiently open and unobstructed so that a fire or other dangerous condition in any part is obvious to the occupants or supervisory personnel in the area.
(b) Egress capacity is sufficient to provide simultaneously for all the occupants of all communicating levels and areas, with all communicating levels in the same fire area being considered as a single floor area for purposes of determination of required egress capacity.
(c) The height between the highest and lowest finished floor levels shall not exceed 13 ft (4 m); the number of levels shall not be restricted.
Exception No. 4: Unprotected openings in accordance with 8.2.5.5 shall not be permitted.
Exception No. 5: Where a full enclosure of a stairway that is not a required exit is impracticable, the required enclosure shall be permitted to be limited to that necessary to prevent a fire originating in any story from spreading to any other story.

19.3.1.2 A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position.
Exception: Doors in stair enclosures held open under the conditions specified by 19.2.2.2.6 and 19.2.2.2.7.

During the facility tour and interviews with the Fire Chief, and the Chief of Plant Operations on 10/28/15, the stairwell enclosures were observed.

Findings:

Unit B
1. At 1:05 p.m., the first level stairwell door #105 failed to self close and latch. The door failed to close in three out of three attempts from the fully open position.

2. At 1:06 p.m., the Chief of Plant Operations confirmed that there was interference at the latch and strike plate.

3. At 1:10 p.m., the second level stairwell door #28, to the penthouse mechanical room, failed to self close and latch. The door failed to close completely in three out of three attempts from the fully open position.

4. At 1:11 p.m., the Chief of Plant Operations confirmed there was an air pressure differential that left the door slightly open.

5. At 1:13 p.m., the second level stairwell door #201, into the B Unit, failed to self close the last three inches. The door failed to close completely in three out of three attempts from the fully open position.

6. At 1:14 p.m., the Chief of Plant Operations confirmed there was an air pressure differential that left the door slightly open.

7. At 1:13 p.m., the second level stairwell door #235, from the B Unit to the exterior stairwell, failed to self close and latch. The Fire Chief confirmed that the bottom of the door scraped along the floor tile near the door frame.

Based on observation and interview, the facility failed to maintain their electrical wiring. This was evidenced by an exposed electrical conductor in an empty light bulb socket. This could result in electrocution or an electrical fire. This affected one of three smoke compartments.

NAPA 101, Life Safety Code, 2000 Edition.
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NAPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NAPA 70, National Electrical Code, 1999 Edition.
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Findings:

During a facility tour with the Fire Chief and the Plant Operations Supervisor on 10/28/15, the electrical wiring was observed, and staff was interviewed.

1. At 1:29 p.m., there was an exposed electrical conductor in the light socket for the overhead light fixture in the Janitor's Closet 244 A. There was no bulb and no fixture canopy.

2. At 1:30 p.m., the Plant Operations Supervisor confirmed that the bulb was necessary to keep the conducting surfaces from being exposed.

Based on observation and interview, the facility failed to ensure that there was no impediments to closing the corridor doors. This was evidenced by 13 doors on the B Unit and 3 doors on the W-1 Unit that failed to self close and latch. This could result in a delay to contain fire or smoke during a fire. This affected three of three smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3 Corridor Doors.
19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
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: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.

19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour with the Fire Chief, and the Chief of Plant Operations on 10/28/15, the corridor doors were observed.

B Unit
1. At 1:25 p.m., door 233A was equipped with a door closer that failed to self-close and latch.

2. At 1:28 p.m., door 244A was equipped with a door closer that failed to self-close and latch.

3. At 1:29 p.m., door 232 was equipped with a door closer that failed to self-close and latch.

4. At 1:33 p.m., door 232A was equipped with a door closer that failed to self-close and latch.

5. At 1:35 p.m., door 228 was equipped with a door closer that failed to self-close and latch.

6. At 1:37 p.m., door 238 was equipped with a door closer that failed to self-close and latch.

7. At 1:40 p.m., door 226 was equipped with a door closer that failed to self-close and latch.

8. At 1:42 p.m., door 224 was equipped with a door closer that failed to self-close and latch.

9. At 1:44 p.m., door 229 was equipped with a door closer with the latch mechanism missing.

10. At 1:48 p.m., door 224 was equipped with a door closer that failed to self-close and latch

11. At 1:52 p.m., door 219 was equipped with a door closer that failed to self-close and latch.

12. At 1:53 p.m., door 216 was equipped with a door closer but the latch mechanism was missing.

13. At 1:54 p.m., door 233 was equipped with a door closer that failed to self-close and latch.

W-1 Unit
14. At 1:57 p.m., the washer and dryer room door failed to close and latch.

15. At 2:01 p.m., the door to Room 1154 was equipped with a door closer that failed to self-close and latch.

16. At 2:02 p.m., the door to Room 1155 was equipped with a door closer that failed to self-close and latch.

17. At 2:03 p.m., during interview, Nurse Staff 1 stated that the corridor doors suffered repeat failures since the last repair. Nurse Staff 1 pointed to the work order copies that were placed on the doors for Rooms 1154 and 1155 a few days earlier.

Based on observation and interview, the facility failed to ensure that stairwell openings maintained a safe path of escape with fire protection. This was evidenced by stairwell doors that failed to close and latch in Unit B on the second floor. This could result in the spread of fire or smoke in the event of a fire. This affected two of three smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
Exception No. 1: Unprotected vertical openings in accordance with 8.2.5.8 shall be permitted.
Exception No. 2: Exception No. 1 to 8.2.5.6(1) shall not apply to patient sleeping and treatment rooms.
Exception No. 3: Multilevel patient sleeping areas in psychiatric facilities shall be permitted without enclosure protection between levels, provided that all the following conditions are met:
(a) The entire normally occupied area, including all communicating floor levels, is sufficiently open and unobstructed so that a fire or other dangerous condition in any part is obvious to the occupants or supervisory personnel in the area.
(b) Egress capacity is sufficient to provide simultaneously for all the occupants of all communicating levels and areas, with all communicating levels in the same fire area being considered as a single floor area for purposes of determination of required egress capacity.
(c) The height between the highest and lowest finished floor levels shall not exceed 13 ft (4 m); the number of levels shall not be restricted.
Exception No. 4: Unprotected openings in accordance with 8.2.5.5 shall not be permitted.
Exception No. 5: Where a full enclosure of a stairway that is not a required exit is impracticable, the required enclosure shall be permitted to be limited to that necessary to prevent a fire originating in any story from spreading to any other story.

19.3.1.2 A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position.
Exception: Doors in stair enclosures held open under the conditions specified by 19.2.2.2.6 and 19.2.2.2.7.

During the facility tour and interviews with the Fire Chief, and the Chief of Plant Operations on 10/28/15, the stairwell enclosures were observed.

Findings:

Unit B
1. At 1:05 p.m., the first level stairwell door #105 failed to self close and latch. The door failed to close in three out of three attempts from the fully open position.

2. At 1:06 p.m., the Chief of Plant Operations confirmed that there was interference at the latch and strike plate.

3. At 1:10 p.m., the second level stairwell door #28, to the penthouse mechanical room, failed to self close and latch. The door failed to close completely in three out of three attempts from the fully open position.

4. At 1:11 p.m., the Chief of Plant Operations confirmed there was an air pressure differential that left the door slightly open.

5. At 1:13 p.m., the second level stairwell door #201, into the B Unit, failed to self close the last three inches. The door failed to close completely in three out of three attempts from the fully open position.

6. At 1:14 p.m., the Chief of Plant Operations confirmed there was an air pressure differential that left the door slightly open.

7. At 1:13 p.m., the second level stairwell door #235, from the B Unit to the exterior stairwell, failed to self close and latch. The Fire Chief confirmed that the bottom of the door scraped along the floor tile near the door frame.

Based on observation and interview, the facility failed to maintain their electrical wiring. This was evidenced by an exposed electrical conductor in an empty light bulb socket. This could result in electrocution or an electrical fire. This affected one of three smoke compartments.

NAPA 101, Life Safety Code, 2000 Edition.
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NAPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NAPA 70, National Electrical Code, 1999 Edition.
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Findings:

During a facility tour with the Fire Chief and the Plant Operations Supervisor on 10/28/15, the electrical wiring was observed, and staff was interviewed.

1. At 1:29 p.m., there was an exposed electrical conductor in the light socket for the overhead light fixture in the Janitor's Closet 244 A. There was no bulb and no fixture canopy.

2. At 1:30 p.m., the Plant Operations Supervisor confirmed that the bulb was necessary to keep the conducting surfaces from being exposed.