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Based on observations, the facility failed to properly protect corridors from use areas in accordance to NFPA 101 sections 19.3.6.2.1, 19.3.6.1 (Exception 6). This deficiency affected three (3) of four (4) smoke compartments in the building.

Findings include:

On March 1, 2016 at 12:00 PM, observation revealed the corridor walls had numerous unsealed penetrations located randomly throughout the patient sleeping areas of the building. The facility was not protected with an automatic fire sprinkler system. It was also observed the corridor wall near the Kitchen did not terminate at the underside of the ceiling. On March 1, 2016 at 1:00 PM, observation revealed
the Employee Break Room was open to the corridor, requiring the Employee Break Room to be supervised with automatic smoke detector or to be separated with 20 minute fire rated doors.

The maintenance person agreed with these findings on March 1, 2016.

19.3.6.2.1*
Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.

19.3.6.1
Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.)

Exception No. 6: Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be permitted to be open to the corridor and unlimited in area, provided that the following criteria are met:
(a) The space and the corridors onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(b) * Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arrangement that a fully developed fire is unlikely to occur.
(c) The space does not obstruct access to required exits.

Based on observations, the facility failed to properly maintain smoke barrier walls for the purpose of providing one (1) half hour fire resistance in accordance to NFPA 101 section 19.3.7.3, 19.3.7.5, and 8.3. These deficiencies affected four (4) of four (4) smoke compartments in the building on the day of survey.


Findings Include:

On March 1, 2016 at 12:50 PM, observation revealed the smoke barrier walls had unsealed penetrations on both sides of the wall above the ceiling in the following areas of the facility:

1. Smoke barrier wall near the Gero-Pysch Hall
2. Smoke barrier wall near the Acute Hall
3. Smoke barrier wall near the Diagnostics Area

The maintenance person agreed with these findings on March 1, 201

Based on observations, the facility failed to provide a properly installed and maintained fire alarm system as directed by NFPA 72 section 1-5.6. These deficiencies affected four (4) of four (4) smoke compartments in the building on the day of survey.

Findings Include:

On March 1, 2016 at 10:15 AM, observations revealed the location of the automatic dialer of the fire alarm system lack being supervised by a hard wired smoke/heat detector and the automatic dialer was not located in a continuously staff occupied/supervised area.

On March 1, 2016 at 10:30 AM, observation also revealed the fire alarm panel was showing trouble signal and the panel could be reset by the maintenance director.

The maintenance person agreed with these findings on March 1, 2016.

1-5.6* Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic
smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.

Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

Based on observations, the facility failed to properly protect corridors from use areas in accordance to NFPA 101 sections 19.3.6.2.1, 19.3.6.1 (Exception 6). This deficiency affected three (3) of four (4) smoke compartments in the building.

Findings include:

On March 1, 2016 at 12:00 PM, observation revealed the corridor walls had numerous unsealed penetrations located randomly throughout the patient sleeping areas of the building. The facility was not protected with an automatic fire sprinkler system. It was also observed the corridor wall near the Kitchen did not terminate at the underside of the ceiling. On March 1, 2016 at 1:00 PM, observation revealed
the Employee Break Room was open to the corridor, requiring the Employee Break Room to be supervised with automatic smoke detector or to be separated with 20 minute fire rated doors.

The maintenance person agreed with these findings on March 1, 2016.

19.3.6.2.1*
Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.

19.3.6.1
Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.)

Exception No. 6: Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be permitted to be open to the corridor and unlimited in area, provided that the following criteria are met:
(a) The space and the corridors onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(b) * Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arrangement that a fully developed fire is unlikely to occur.
(c) The space does not obstruct access to required exits.

Based on observations, the facility failed to properly maintain smoke barrier walls for the purpose of providing one (1) half hour fire resistance in accordance to NFPA 101 section 19.3.7.3, 19.3.7.5, and 8.3. These deficiencies affected four (4) of four (4) smoke compartments in the building on the day of survey.


Findings Include:

On March 1, 2016 at 12:50 PM, observation revealed the smoke barrier walls had unsealed penetrations on both sides of the wall above the ceiling in the following areas of the facility:

1. Smoke barrier wall near the Gero-Pysch Hall
2. Smoke barrier wall near the Acute Hall
3. Smoke barrier wall near the Diagnostics Area

The maintenance person agreed with these findings on March 1, 201

Based on observations, the facility failed to provide a properly installed and maintained fire alarm system as directed by NFPA 72 section 1-5.6. These deficiencies affected four (4) of four (4) smoke compartments in the building on the day of survey.

Findings Include:

On March 1, 2016 at 10:15 AM, observations revealed the location of the automatic dialer of the fire alarm system lack being supervised by a hard wired smoke/heat detector and the automatic dialer was not located in a continuously staff occupied/supervised area.

On March 1, 2016 at 10:30 AM, observation also revealed the fire alarm panel was showing trouble signal and the panel could be reset by the maintenance director.

The maintenance person agreed with these findings on March 1, 2016.

1-5.6* Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic
smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.

Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.