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Based on observation and interview, the facility failed to ensure that corridor doors to hazardous areas were equipped with door closing devices as required.

The findings include:

During the Life Safety Code survey on November 10, 2010, at 9:30 a.m., with the Director of Maintenance (DOM), a corridor door to the equipment supply room was observed not to have a self-closing device as required. In addition, the outpatient clinic storage room door and the pharmacy supply room door were observed not to have a self-closing device.
An interview with the DOM on November 10, 2010, at 9:30 a.m., revealed the DOM was unsure which doors would be required to have a self-closing device.

Reference: NFPA 101 (2000 Edition).

19.3.2.1 Hazardous Areas.
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. 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.Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observation and interview, the facility failed to ensure that the building fire alarm system functioned as required by NFPA standards.

The findings include:

During the Life Safety Code survey on November 10, 2010, at 9:20 a.m., with the Director of Maintenance (DOM), a test of the fire alarm automatic dialer panel revealed when the panel was placed in trouble from phone line failure the unit sent a trouble signal to a continuously occupied location within the facility, however, the monitoring station did not directly notify the facility of this phone line failure as required. The monitoring station left a message on the DOM's answering machine. An interview with the DOM on November 10, 2010 at 9:20 a.m., revealed the DOM was going to contact the monitoring station to leave them certain telephone numbers and instructions in case of future phone line failures.

Reference: NFPA 72 (1999 Edition).

5-2.6.1.4
Upon receipt of trouble signals or other signals pertaining solely to matters of equipment maintenance of the fire alarm systems, the central station shall perform the following actions:
(1) *Communicate immediately with persons designated by the subscriber
A-5-2.6.1.4(1)
The term immediately in this context is intended to mean " without unreasonable delay. " Routine handling should take a maximum of 4 minutes from receipt of a trouble signal by the central station until initiation of the investigation by telephone.

Based on observation and interview, the facility failed to ensure kitchen appliances were properly maintained as required.

The findings include:

During the Life Safety Code tour on November 10, 2010, at 10:55 a.m., with the Director of Maintenance (DOM), a deep fryer was observed adjacent to a gas cooking range in the kitchen area. These two items must be separated or protected to prevent an accidental fire from occurring. An interview on November 10, 2010, at 10:55 a.m., revealed the DOM had been recently made aware of this requirement by range hood technicians. However, the DOM had taken no action to correct the problem.

Reference: NFPA 96 (1998 Edition).
9-1.2.3
All deep fat fryers shall be installed with at least a 16-in. (406.4-mm) space between the fryer and surface flames from adjacent cooking equipment.
Exception: Where a steel or tempered glass baffle plate is installed at a minimum 8 in. (203 mm) in height between the fryer and surface flames of the adjacent appliance.

Based on observation and interview, the facility failed to ensure that corridor doors to hazardous areas were equipped with door closing devices as required.

The findings include:

During the Life Safety Code survey on November 10, 2010, at 9:30 a.m., with the Director of Maintenance (DOM), a corridor door to the equipment supply room was observed not to have a self-closing device as required. In addition, the outpatient clinic storage room door and the pharmacy supply room door were observed not to have a self-closing device.
An interview with the DOM on November 10, 2010, at 9:30 a.m., revealed the DOM was unsure which doors would be required to have a self-closing device.

Reference: NFPA 101 (2000 Edition).

19.3.2.1 Hazardous Areas.
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. 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.Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observation and interview, the facility failed to ensure that the building fire alarm system functioned as required by NFPA standards.

The findings include:

During the Life Safety Code survey on November 10, 2010, at 9:20 a.m., with the Director of Maintenance (DOM), a test of the fire alarm automatic dialer panel revealed when the panel was placed in trouble from phone line failure the unit sent a trouble signal to a continuously occupied location within the facility, however, the monitoring station did not directly notify the facility of this phone line failure as required. The monitoring station left a message on the DOM's answering machine. An interview with the DOM on November 10, 2010 at 9:20 a.m., revealed the DOM was going to contact the monitoring station to leave them certain telephone numbers and instructions in case of future phone line failures.

Reference: NFPA 72 (1999 Edition).

5-2.6.1.4
Upon receipt of trouble signals or other signals pertaining solely to matters of equipment maintenance of the fire alarm systems, the central station shall perform the following actions:
(1) *Communicate immediately with persons designated by the subscriber
A-5-2.6.1.4(1)
The term immediately in this context is intended to mean " without unreasonable delay. " Routine handling should take a maximum of 4 minutes from receipt of a trouble signal by the central station until initiation of the investigation by telephone.

Based on observation and interview, the facility failed to ensure kitchen appliances were properly maintained as required.

The findings include:

During the Life Safety Code tour on November 10, 2010, at 10:55 a.m., with the Director of Maintenance (DOM), a deep fryer was observed adjacent to a gas cooking range in the kitchen area. These two items must be separated or protected to prevent an accidental fire from occurring. An interview on November 10, 2010, at 10:55 a.m., revealed the DOM had been recently made aware of this requirement by range hood technicians. However, the DOM had taken no action to correct the problem.

Reference: NFPA 96 (1998 Edition).
9-1.2.3
All deep fat fryers shall be installed with at least a 16-in. (406.4-mm) space between the fryer and surface flames from adjacent cooking equipment.
Exception: Where a steel or tempered glass baffle plate is installed at a minimum 8 in. (203 mm) in height between the fryer and surface flames of the adjacent appliance.