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Based on testing and observation, it was determined the facility failed to maintain the ventilation system.

The finding included:

Observation on 2/5/13 at 9:54 AM revealed the utility and mop closet in the kitchen had positive air pressure.

This finding was acknowledged by the maintenance director and the facility administrator during the exit interview on 2/5/13.

National Fire Protection Association 101 Life Safety Code
8.2.3.2.4 Penetrations and Miscellaneous Openings in Fire Barriers.
8.2.3.2.4.1*
Openings in fire barriers for air-handling ductwork or air movement shall be protected in accordance with 9.2.1.
8.2.3.2.4.2*
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, it was determined the facility failed to comply with the Life Safety Code.

The findings included:

1. Observation on 2/5/13 at 9:10 AM revealed penetrations in the fire barrier around conduit and cables in electrical room near patient room 130.

2. Observation on 2/5/13 at 9:15 AM revealed penetrations in the ceiling around pipe hangers in the water heater room in the physical therapy room.

3. Observation on 2/5/13 at 9:31 AM revealed a penetration in the fire barrier where the wall meets the roof by patient room 106.

4. Observation on 2/5/13 at 9:57 AM revealed a penetration in the fire barrier adjacent to the Health Information Management office.

These findings were acknowledged by the maintenance director and the facility administrator during the exit interview on 2/5/13.

Based on observations, it was determined the facility failed to maintain the electrical equipment.

The findings included:

1. Observation on 2/5/13 at 8:47 AM revealed electric panel EC in the electrical room with the generator was missing a cover for empty circuit slot.

2. Observation on 2/5/13 at 9:15 AM revealed storage in front of electric disconnect for water heaters in water heater closet connected to physical therapy room.

These findings were acknowledged by the maintenance director and the facility administrator during the exit interview on 2/5/13.

Based on testing and observation, it was determined the facility failed to maintain the ventilation system.

The finding included:

Observation on 2/5/13 at 9:54 AM revealed the utility and mop closet in the kitchen had positive air pressure.

This finding was acknowledged by the maintenance director and the facility administrator during the exit interview on 2/5/13.

National Fire Protection Association 101 Life Safety Code
8.2.3.2.4 Penetrations and Miscellaneous Openings in Fire Barriers.
8.2.3.2.4.1*
Openings in fire barriers for air-handling ductwork or air movement shall be protected in accordance with 9.2.1.
8.2.3.2.4.2*
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, it was determined the facility failed to comply with the Life Safety Code.

The findings included:

1. Observation on 2/5/13 at 9:10 AM revealed penetrations in the fire barrier around conduit and cables in electrical room near patient room 130.

2. Observation on 2/5/13 at 9:15 AM revealed penetrations in the ceiling around pipe hangers in the water heater room in the physical therapy room.

3. Observation on 2/5/13 at 9:31 AM revealed a penetration in the fire barrier where the wall meets the roof by patient room 106.

4. Observation on 2/5/13 at 9:57 AM revealed a penetration in the fire barrier adjacent to the Health Information Management office.

These findings were acknowledged by the maintenance director and the facility administrator during the exit interview on 2/5/13.

Based on observations, it was determined the facility failed to maintain the electrical equipment.

The findings included:

1. Observation on 2/5/13 at 8:47 AM revealed electric panel EC in the electrical room with the generator was missing a cover for empty circuit slot.

2. Observation on 2/5/13 at 9:15 AM revealed storage in front of electric disconnect for water heaters in water heater closet connected to physical therapy room.

These findings were acknowledged by the maintenance director and the facility administrator during the exit interview on 2/5/13.