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19.3.1.1, NFPA 101, LIFE SAFETY CODE
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.

8.2.3.2.1, NFPA 101, LIFE SAFETY CODEDoor assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

1-6.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled fire doors shall be used.

2-3.1.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled door frames shall be used.

Based on observation and interview the facility failed to ensure that all fire rated, enclosed stairwells have fire doors with labels.

Findings include:

Observation during tour on 6/13/12 with Staff B (Facilities Director) and Staff C (Maintenance) revealed that the fire barrier of the enclosed stairwell that separates the Physical Therapy room from the green stairwell has a door assembly that does not have a fire rating label.

Interview during tour on 6/13/12 with Staff B confirmed the findings.

19.3.2.1, NFPA 101, LIFE SAFETY CODE
Hazardous Areas: Any hazardous areas shall be safe-guarded 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. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

8.4.1.3, NFPA 101, LIFE SAFETY CODE
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.

7.2.1.8.1, NFPA 101, LIFE SAFETY CODE
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.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that hazardous areas are equipped with self-closing doors and that they are properly maintained.

Findings include:

Observation during tour on 6/13/12 between 1:45 p.m. and 2:15 p.m. with Staff B (Facilities Director) and Staff C (Maintenance) revealed the following:

1. The Emergency Department has at least one Soiled Utility Room that does not have a self-closing door installed.

2. The Coos County Family Health Services Records Room has two self-closing doors installed with hold-open devices where one of the doors is obstructed by a door stop from connecting to the hold-open device and is held open with a door wedge.

Interview during tour on 6/13/12 with Staff B at the time of discovery confirmed the findings.

19.2.10.1, NFPA 101, LIFE SAFETY CODE
Means of egress shall have signs in accordance with Section 7.10.

7.10.1.2, NFPA 101, LIFE SAFETY CODE
Exits: Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.2, NFPA 101, LIFE SAFETY CODE
Directional Signs: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Based on observation and interview the facility failed to ensure that exits have visible exit signs.

Findings include:

Observation during tour on 6/13/12 at approximately 2:45 p.m. with Staff B (Facility Director) and Staff C (Maintenance) revealed that one the door inside the lab located on level 2 which enters into a corridor and serves as a means of egress does not have an exit sign installed.

Interview during tour on 6/13/12 with Staff B at the time of discovery confirmed the findings.

19.3.1.1, NFPA 101, LIFE SAFETY CODE
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.

8.2.3.2.1, NFPA 101, LIFE SAFETY CODEDoor assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

1-6.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled fire doors shall be used.

2-3.1.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled door frames shall be used.

Based on observation and interview the facility failed to ensure that all fire rated, enclosed stairwells have fire doors with labels.

Findings include:

Observation during tour on 6/13/12 with Staff B (Facilities Director) and Staff C (Maintenance) revealed that the fire barrier of the enclosed stairwell that separates the Physical Therapy room from the green stairwell has a door assembly that does not have a fire rating label.

Interview during tour on 6/13/12 with Staff B confirmed the findings.

19.3.2.1, NFPA 101, LIFE SAFETY CODE
Hazardous Areas: Any hazardous areas shall be safe-guarded 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. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

8.4.1.3, NFPA 101, LIFE SAFETY CODE
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.

7.2.1.8.1, NFPA 101, LIFE SAFETY CODE
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.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that hazardous areas are equipped with self-closing doors and that they are properly maintained.

Findings include:

Observation during tour on 6/13/12 between 1:45 p.m. and 2:15 p.m. with Staff B (Facilities Director) and Staff C (Maintenance) revealed the following:

1. The Emergency Department has at least one Soiled Utility Room that does not have a self-closing door installed.

2. The Coos County Family Health Services Records Room has two self-closing doors installed with hold-open devices where one of the doors is obstructed by a door stop from connecting to the hold-open device and is held open with a door wedge.

Interview during tour on 6/13/12 with Staff B at the time of discovery confirmed the findings.

19.2.10.1, NFPA 101, LIFE SAFETY CODE
Means of egress shall have signs in accordance with Section 7.10.

7.10.1.2, NFPA 101, LIFE SAFETY CODE
Exits: Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.2, NFPA 101, LIFE SAFETY CODE
Directional Signs: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Based on observation and interview the facility failed to ensure that exits have visible exit signs.

Findings include:

Observation during tour on 6/13/12 at approximately 2:45 p.m. with Staff B (Facility Director) and Staff C (Maintenance) revealed that one the door inside the lab located on level 2 which enters into a corridor and serves as a means of egress does not have an exit sign installed.

Interview during tour on 6/13/12 with Staff B at the time of discovery confirmed the findings.