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Based on observation, record review and staff interview, the facility failed to provide a flame spread rating of Class A, B, or C for the exposed interior walls of a room that is not used for an exit way. This deficient practice would allow for flame to spread more rapidly across the surface of the exposed wall treatment, affecting one of twenty-one smoke zones. The facility has a capacity of 74 with a census of 30 at the time of survey.

Findings Include:

During the tour beginning on June 27, 2011 at 9:30 AM and ending on June 28th, 2011 at 2:30 PM the following is observed:

The 2nd floor behavior unit has accordion doors to section off portions of the day room. No documentation of flame spread could be produced to indicate the flame spread rating for the material used to form these movable wall sections.

Staff A and Staff B were present at the time of the findings and both stated that the accordion doors had been in the facility for a long time and no documentation of flame spread was available for review.

NFPA Standard: Ceiling and wall materials shall be limited as specified in 2000 NFPA 101, 10.2.3 Existing materials may be Class A or Class B except that rooms protected by an approved, supervised automatic sprinkler system use of existing Class C finish shall be permitted within rooms separated from the exit access corridors in accordance with 19.3.6. New materials must be Class A except that new walls/ceilings shall be permitted to have Class A or Class B finish in individual rooms having a capacity of four persons. Newly installed corridor wall finish not exceeding 4 feet in height on the lower half of the wall shall be permitted to be Class A or Class B. 2000 NFPA 101, 19.3.3.2.

NFPA Standard: Textile materials having a Class A rating (see 10.2.3.2) shall be permitted to extend not more than 4 ft (1.2m) above the finished floor on ceiling height walls and ceiling height partitions. 2000 NFPA 101, 10.2.4.1.3

NFPA Standard: Products required to be tested in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0 25; smoke development 0 450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26 75; smoke development 0 450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76 200; smoke development 0 450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale.
Exception: Existing interior finish shall be exempt from the smoke development criteria. 2000 NFPA 101, 10.2.3.2

Based on observation and staff interview the facility is not ensuring that all corridor room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting two of twenty-one smoke zones. The facility has a capacity of 74 with a census of 30 at the time of survey.

Findings Include:

During the tour beginning on June 27, 2011 at 9:30 AM and ending on June 28th, 2011 at 2:30 PM the following is observed:

The door to room 2337 does not have latching hardware.

Staff A and Staff B were present at the time of the finding. Staff B stated that the reason the latching mechanism had been removed from this door was due to replacement of door hardware. Staff B stated repairs would be made as soon as possible.

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, 19.3.6.3.1 and 19.3.6.3

Based on observation, staff interview and record review, the facility failed to maintain the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being available at the time of a power loss, affecting 21 of 21 smoke zones. The facility has a capacity of 74 with a census of 30 at the time of survey.

Findings Include:

During the tour on beginning June 27, 2011 at 9:30 AM and ending on June 28th, 2011 at 2:30 PM the following is observed:

1. The Type 1 essential electrical systems are not comprised of two separate systems.
2. The annunciator for the generator is located in the maintenance department office and this is not a constantly attended area.

Staff B stated that the maintenance office and maintenance department is not constantly attended and the alarm annunciation is not arranged to provide an audible and visual derangement signal in at a continuously monitored location. Staff B also confirmed that the essential electrical system is not divided into the life safety and critical patient care branches.

NFPA Standard: Alarm Annunciation where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuous monitored location. 1999 NFPA 99, 3-4.1.1.15

NFPA Standard: Type I essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective facility operation during the time the normal electrical service is interrupted for any reason. These two systems are the emergency and the equipment system.
The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch. The equipment system shall supply major electrical equipment necessary for patient care and basic Type I operation. Both systems shall be arranged for connection, within time following a loss of the normal source. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW). 1999 NFPA 99, 3-4,2.2.1