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During the revisit, items 1-4 had been corrected, item #5 the hole in the ceiling approximately 2' x 2' in Room 111 has not been repaired. Based on observation and interview with the Plant Operation Director, the leak has not been repaired. This must be corrected before the hole in the ceiling can be repaired.

Room 111 also had a hole in the ceiling approximately 2' X 2' from a roof leak.

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
.

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During the revisit, items 3 and 4 had not been corrected. Based on interview with the Plant Operation Director, materials would be picked up on 3/30/2011, so these items could be corrected.


3. Two emergency room doors were not positive latching, doors open into the corridor.

4. The Laboratory Room, next to Admissions Switchboard, the corridor door had a roller latch.


2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
2000 NFPA 101, 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.

During the revisit, items #2, and #3 had not been corrected. Based on interview with the Plant Operation Director, materials would be picked up on 3/30/2011, to correct these items.


2. The Supply Room - was being used for combustible storage, the room did have sprinkler coverage and the room is over 100 sq. ft.:
a. The door to the Lobby did not have positive latching hardware
b. The Office door connected to the Supply Room did not have a self-closing device

3. The Dietary Storage Room was being used for combustible storage, the room did not have sprinkler coverage and the room was over
50 sq. ft.:

a. The door was not 45 minute fire rated
b. The door did not have a self-closing device

2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

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**The facility has requested a wavier for this tag and will be completed by 6/18/2011.

The facility failed to provide a reliable means of egress to the public way:

Findings include: During the survey, the following are examples of what was observed:

1. The Exit Discharge for the Exit by Patient Room 111 was not provided with an all weather surface to the public way.

2. The Northeast Exit was observed with stairs that ended in a grassy area.



2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
2000 NFPA 101, 7.7.1 Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.