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Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting 2 of 7 smoke zones. The facility has a capacity of 18 with a census of 3 in the hospital portion and a capacity of 25 with a census of 17 in the LTCU portion at the time of the survey.

Findings include:

During the tour conducted on 04/02/2012, at 1:50 p.m., it is observed:

-- 1. Smoke barrier wall separating the hospital and the LTCU, south corridor, has openings created by removal of temporary ductwork.

Maintenance Staff A and B were present and acknowledged the open areas in the smoke barrier. On-site contractor made repairs to the smoke barrier wall prior to the conclusion of the survey.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based upon observation and staff interview, the facility fails to assure that vision panels are of fire-rated glazing or wired panels and are in approved frames. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting 2 of 7 smoke zones. The facility has a capacity of 18 with a census of 3 in the hospital portion and a capacity of 25 with a census of 17 in the LTCU portion at the time of the survey.

Findings include:

During the tour conducted on 04/02/2012, at 10:00 a.m., it is observed that smoke barrier doors near the Hospital's Nurses Station have openings for vision panels but no glass or frame is installed.
Administrative Staff A, Maintenance Staff A and B, and on-site contractors were present and acknowledged the findings. Superintendent for the construction project stated that the windows and frames would be installed within the next week.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 18.3.6.3.1, 18.3.6.2 and 18.3.6.3

Based on observation and staff interview, the facility fails to ensure proper separation of hazardous areas from other spaces. This deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 1 of 7 smoke zones. The facility has a capacity of 18 with a census of 3 in the hospital portion and a capacity of 25 with a census of 17 in the LTCU portion at the time of this survey

Findings include:

During the tour conducted on 04/03/2012, it is observed that within hazardous rooms identified as "Maint." and "Chiller Room", there are numerous unsealed penetrations in the ceiling and walls where utilities have been replaced.

Maintenance Staff A and B were present and acknowledged the findings. On-site Construction Superintendent A indicated that the penetrations would be sealed as soon as possible using approved methods.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

Based on observation and staff interview, the facility fails to assure that means of egress are continuously maintained free of all obstructions or impediments. The deficient practice would prevent the full instant use of the egress pathway, affecting 1 of 7 smoke zones. The facility has a capacity of 18 with a census of 3 in the hospital portion and a capacity of 25 with a census of 17 in the LTCU portion at the time of the survey.

Findings include:

During the tour conducted on 04/03/2012, it is observed:

-- 1. At 1:20 p.m., unsecured items (planter, stand) stored near designated exit in Activity Room.

-- 2. At 1:30 p.m., unsecured items (planter, stand) stored near northwest exit from LTCU.

Maintenance Staff A was present, acknowledged the presence of the items, and assured that the items in question would be relocated.

NFPA Standard: Requires that no furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom or visibility thereof.

Based upon observation and staff interview, the facility fails to assure that electrical wiring is in accordance with NFPA 70. The deficient practice increases the risk of an electrical fire, affecting 1 of 7 smoke zones. The facility has a capacity of 18 with a census of 3 in the hospital portion and a capacity of 25 with a census of 17 in the LTCU portion at the time of the survey.


FINDINGS INCLUDE:

During the tour conducted on 04/03/2012, it is observed:

-- 1. At 1:32 p.m., in the Beauty Shop, an extension cord is used to provide electricity to an electric water heater.

-- 2. At 2:09 p.m., in the Oxygen Storage Room, 3 junction boxes without covers.

Maintenance Staff A and B were present and acknowledged the findings. Maintenance Staff B immediately removed the temporary extension cord. An on-site contractor placed covers on the junction boxes prior to the conclusion of the survey.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting 2 of 7 smoke zones. The facility has a capacity of 18 with a census of 3 in the hospital portion and a capacity of 25 with a census of 17 in the LTCU portion at the time of the survey.

Findings include:

During the tour conducted on 04/02/2012, at 1:50 p.m., it is observed:

-- 1. Smoke barrier wall separating the hospital and the LTCU, south corridor, has openings created by removal of temporary ductwork.

Maintenance Staff A and B were present and acknowledged the open areas in the smoke barrier. On-site contractor made repairs to the smoke barrier wall prior to the conclusion of the survey.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based upon observation and staff interview, the facility fails to assure that vision panels are of fire-rated glazing or wired panels and are in approved frames. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting 2 of 7 smoke zones. The facility has a capacity of 18 with a census of 3 in the hospital portion and a capacity of 25 with a census of 17 in the LTCU portion at the time of the survey.

Findings include:

During the tour conducted on 04/02/2012, at 10:00 a.m., it is observed that smoke barrier doors near the Hospital's Nurses Station have openings for vision panels but no glass or frame is installed.
Administrative Staff A, Maintenance Staff A and B, and on-site contractors were present and acknowledged the findings. Superintendent for the construction project stated that the windows and frames would be installed within the next week.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 18.3.6.3.1, 18.3.6.2 and 18.3.6.3

Based on observation and staff interview, the facility fails to ensure proper separation of hazardous areas from other spaces. This deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 1 of 7 smoke zones. The facility has a capacity of 18 with a census of 3 in the hospital portion and a capacity of 25 with a census of 17 in the LTCU portion at the time of this survey

Findings include:

During the tour conducted on 04/03/2012, it is observed that within hazardous rooms identified as "Maint." and "Chiller Room", there are numerous unsealed penetrations in the ceiling and walls where utilities have been replaced.

Maintenance Staff A and B were present and acknowledged the findings. On-site Construction Superintendent A indicated that the penetrations would be sealed as soon as possible using approved methods.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

Based on observation and staff interview, the facility fails to assure that means of egress are continuously maintained free of all obstructions or impediments. The deficient practice would prevent the full instant use of the egress pathway, affecting 1 of 7 smoke zones. The facility has a capacity of 18 with a census of 3 in the hospital portion and a capacity of 25 with a census of 17 in the LTCU portion at the time of the survey.

Findings include:

During the tour conducted on 04/03/2012, it is observed:

-- 1. At 1:20 p.m., unsecured items (planter, stand) stored near designated exit in Activity Room.

-- 2. At 1:30 p.m., unsecured items (planter, stand) stored near northwest exit from LTCU.

Maintenance Staff A was present, acknowledged the presence of the items, and assured that the items in question would be relocated.

NFPA Standard: Requires that no furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom or visibility thereof.

Based upon observation and staff interview, the facility fails to assure that electrical wiring is in accordance with NFPA 70. The deficient practice increases the risk of an electrical fire, affecting 1 of 7 smoke zones. The facility has a capacity of 18 with a census of 3 in the hospital portion and a capacity of 25 with a census of 17 in the LTCU portion at the time of the survey.


FINDINGS INCLUDE:

During the tour conducted on 04/03/2012, it is observed:

-- 1. At 1:32 p.m., in the Beauty Shop, an extension cord is used to provide electricity to an electric water heater.

-- 2. At 2:09 p.m., in the Oxygen Storage Room, 3 junction boxes without covers.

Maintenance Staff A and B were present and acknowledged the findings. Maintenance Staff B immediately removed the temporary extension cord. An on-site contractor placed covers on the junction boxes prior to the conclusion of the survey.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8