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Based on the observation on 01/29/2015 of the corridor walls in nonsprinklered smoke compartments, the facility failed to maintain the construction Type required by code. Findings include:

Majority of Building 0304 was observed to have the construction type of Type II (111) nonsprinklered, except from the Outpatient Nurses' Station to the four hour rated fire wall at the exam rooms that was observed to be of a Type II (000) construction.

This deficiency impacted 1 of 2 smoke compartments of this building.
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Review of 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
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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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Based on the observation on 01/29/2015 of this building's hazardous areas, the facility failed to provide a one hour fire rated enclosure in the nonsprinklered area. Findings include:

The kitchen was observed to be over 50 sq. ft. used for storing all the dietary storage in the kitchen and with gas fueled water heater in the kitchen. The following was observed:
1. The wall between the kitchen and the Serving Area did not continue to the ceiling floor deck above
4. The door between the kitchen and Serving Area did not have positive latching hardware
5. The 2 roll down shutter, one in the corridor wall and in the wall between the Vending room and kitchen, for the pass through the shutters were not fire rated and were not connected to the fire alarm system nor did these shutters have fusible links

During the revisit the facility provided documentation of conducting fire drills every two weeks in the kitchen (for the kitchen staff).

This deficiency impacted 1 of 3 smoke compartments on the First Floor of this building.
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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.

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