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Based on observation the facility failed to provide corridors that are separate from all other areas as per NFPA 101 (Life Safety Code) for 3 of 10 compartments. This deficiency affects any patients using the first floor area of the facility.

Note: NFPA 101, 2000 Edition:

NFPA 101, Chapter 19, "Corridor" 19.3.6.1, Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5.

Findings:

During a tour of the facility conducted from January 9 through January 11, 2013, the East clinic, Central clinic, and radiology have waiting areas, changing areas, charting areas that are open to the corridor without being separated from the corridor by at least a smoke resistive partition. Areas may be open to the corridor, if the area meets the at least one of the exceptions allowed by this code.

Based on observation the facility failed to provide complete protection for 1 of 8 hazardous areas on the first floor as per National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency could have the potential to cause harm to all patients using the first floor area of the facility.

Note: NFPA 101, 2000 Edition:
NFPA 101, Chapter 3, "Protection" 19.3.5.4 if the hazardous areas is sprinkled then the walls and doors to the hazardous area shall be smoke resistive and the door shall be self-closing.

Findings:

During a tour of the facility conducted from January 9 through January 11, 2013, it was observed that the following hazardous areas did not have doors that were positive latching or ceiling that resist the passage of smoke.

1. The double doors of the warehouse area by the loading dock are not positive latching.
The doors do not have a positive latching device on them.

Based on observation the facility failed to provide stair enclosures that comply with NFPA 101 (Life Safety Code) for 2 of 4 stair enclosures. There are door to the stairwells that are not smoke resistive. This deficiency could affect all 44 patients in the facility.

NFPA 101: 19.3.1 Protection of Vertical Openings.
19.3.1.2 A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position.

Findings:

During a tour of the facility conducted from January 9 through January 11, 2013, it was observed that door to the stairs in the following areas have gaps between the door and the frame. The gaps would allow smoke to pass between the stairway and the building.

1. The door at the 6th floor west stairway has a gap between the top of the door and the frame.
2. The door at the 5th floor north stairway has a gap between the top of the door and the frame.

Based on observation the facility failed to provide corridors that are separate from all other areas as per NFPA 101 (Life Safety Code) for 3 of 10 compartments. This deficiency affects any patients using the first floor area of the facility.

Note: NFPA 101, 2000 Edition:

NFPA 101, Chapter 19, "Corridor" 19.3.6.1, Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5.

Findings:

During a tour of the facility conducted from January 9 through January 11, 2013, the East clinic, Central clinic, and radiology have waiting areas, changing areas, charting areas that are open to the corridor without being separated from the corridor by at least a smoke resistive partition. Areas may be open to the corridor, if the area meets the at least one of the exceptions allowed by this code.

Based on observation the facility failed to provide complete protection for 1 of 8 hazardous areas on the first floor as per National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency could have the potential to cause harm to all patients using the first floor area of the facility.

Note: NFPA 101, 2000 Edition:
NFPA 101, Chapter 3, "Protection" 19.3.5.4 if the hazardous areas is sprinkled then the walls and doors to the hazardous area shall be smoke resistive and the door shall be self-closing.

Findings:

During a tour of the facility conducted from January 9 through January 11, 2013, it was observed that the following hazardous areas did not have doors that were positive latching or ceiling that resist the passage of smoke.

1. The double doors of the warehouse area by the loading dock are not positive latching.
The doors do not have a positive latching device on them.

Based on observation the facility failed to provide stair enclosures that comply with NFPA 101 (Life Safety Code) for 2 of 4 stair enclosures. There are door to the stairwells that are not smoke resistive. This deficiency could affect all 44 patients in the facility.

NFPA 101: 19.3.1 Protection of Vertical Openings.
19.3.1.2 A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position.

Findings:

During a tour of the facility conducted from January 9 through January 11, 2013, it was observed that door to the stairs in the following areas have gaps between the door and the frame. The gaps would allow smoke to pass between the stairway and the building.

1. The door at the 6th floor west stairway has a gap between the top of the door and the frame.
2. The door at the 5th floor north stairway has a gap between the top of the door and the frame.