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The facility failed to ensure corridor doors were equipped with automatic latching hardware suitable for keeping the doors closed and resistant to the passage of smoke.

Observation determined:

1) Corridor double doors to the Linen Storage Room by the nurses station did not have automatic latching hardware.

2) The Electrical Equipment Room corridor double doors did not have automatic latching hardware.

3) Corridor double doors to the Linen Storage Room next to Room 109 did not have automatic latching hardware.

Failure to ensure corridor doors are provided with suitable means for keeping the door closed increases the risk for death or injury due to fire.

This deficiency affected six (6) of numerous corridor doors in the facility.

The facility failed to ensure hazardous areas in fully sprinklered existing health care occupancies had smoke resisting partitions and doors equipped with self-closing/automatic latching hardware.

Observation determined the door to the Soiled Linen Room next to the nurses station was not equipped with a self-closing device.

Failure to ensure doors to hazardous areas self-close and latch to the door frame increases the risk or death or injury due to fire.

The deficiency affected one (1) of two (2) hazardous areas on the second floor.

Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
1) Electrical conduit serving the stairway.
2) Required exit doors.
3) Ductwork and equipment necessary for independent stair pressurization.
4) Water or steam piping necessary for the heating and cooling of the exit enclosure.
5) Sprinkler piping.
6) Standpipes.
7.1.3.2.1(e)

The facility failed to protect exit enclosure stairways in accordance with NFPA101, Life Safety Code.

Observation determined a gas line from a propane tank located outside the building penetrated into the east stairway enclosure, then exited the stairway enclosure onto the roof.

Failure to protect exit enclosures increases the risk of death or injury due to fire.

This deficiency affected one (1) of two (2) exit enclosure stairways in the facility.

Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. NFPA 72 A-2-3.5.1

The facility failed to ensure detectors were installed in accordance with NFPA 72, National Fire Alarm Code.

Observation determined two (2) smoke detectors in the Activity Room located two feet from a ceiling fan.

Failure to install detectors in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected two (2) of numerous detectors in the facility.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

Observation determined the following areas lacked adequate sprinkler coverage:
1) The shower area in Room 101.
2) The shower area in Room 102.
3) The shower area in the Central Shower Room.

Failure to install the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire.

The deficiency affected three (3) of numerous areas in the facility.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

All backflow devices installed in fire protection water supply shall be tested annually at the designed flow rate of the fire protection system, including hose stream demands, if appropriate.
Exception: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be conducted at the maximum flow rate possible.

On 03/11/2015, no record of the required annual back flow preventer test was available.

The deficiency affected one of numerous required tests of the automatic sprinkler system. The automatic sprinkler system provides protection to the entire facility.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5, 1998 NFPA 25 Section 9-6.2

Buildings of Type I (332) construction must have vertical shafts constructed with a two-hour fire resistance rating.The facility failed to ensure elevator shafts were enclosed with construction having a fire resistance rating of at least two hours. Observation determined unsealed spaces around the hydraulic pipes from the Elevator Equipment Room to the elevator shaft. The hydraulic pipes ran under the corridor floor from the Elevator Equipment Room to the elevator shaft inside an approximately 12 inch diameter pipe. The area around the hydraulic pipes was not sealed with fire rated material to ensure a two-hour fire resistance rating.

Failure to ensure vertical shafts are constructed with a fire resistance rating of at least two hours increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) elevator shaft in the facility.

The facility failed to ensure corridor doors were equipped with automatic latching hardware suitable for keeping the doors closed and resistant to the passage of smoke.

Observation determined:

1) Corridor double doors to the Linen Storage Room by the nurses station did not have automatic latching hardware.

2) The Electrical Equipment Room corridor double doors did not have automatic latching hardware.

3) Corridor double doors to the Linen Storage Room next to Room 109 did not have automatic latching hardware.

Failure to ensure corridor doors are provided with suitable means for keeping the door closed increases the risk for death or injury due to fire.

This deficiency affected six (6) of numerous corridor doors in the facility.

The facility failed to ensure hazardous areas in fully sprinklered existing health care occupancies had smoke resisting partitions and doors equipped with self-closing/automatic latching hardware.

Observation determined the door to the Soiled Linen Room next to the nurses station was not equipped with a self-closing device.

Failure to ensure doors to hazardous areas self-close and latch to the door frame increases the risk or death or injury due to fire.

The deficiency affected one (1) of two (2) hazardous areas on the second floor.

Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
1) Electrical conduit serving the stairway.
2) Required exit doors.
3) Ductwork and equipment necessary for independent stair pressurization.
4) Water or steam piping necessary for the heating and cooling of the exit enclosure.
5) Sprinkler piping.
6) Standpipes.
7.1.3.2.1(e)

The facility failed to protect exit enclosure stairways in accordance with NFPA101, Life Safety Code.

Observation determined a gas line from a propane tank located outside the building penetrated into the east stairway enclosure, then exited the stairway enclosure onto the roof.

Failure to protect exit enclosures increases the risk of death or injury due to fire.

This deficiency affected one (1) of two (2) exit enclosure stairways in the facility.

Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. NFPA 72 A-2-3.5.1

The facility failed to ensure detectors were installed in accordance with NFPA 72, National Fire Alarm Code.

Observation determined two (2) smoke detectors in the Activity Room located two feet from a ceiling fan.

Failure to install detectors in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected two (2) of numerous detectors in the facility.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

Observation determined the following areas lacked adequate sprinkler coverage:
1) The shower area in Room 101.
2) The shower area in Room 102.
3) The shower area in the Central Shower Room.

Failure to install the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire.

The deficiency affected three (3) of numerous areas in the facility.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

All backflow devices installed in fire protection water supply shall be tested annually at the designed flow rate of the fire protection system, including hose stream demands, if appropriate.
Exception: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be conducted at the maximum flow rate possible.

On 03/11/2015, no record of the required annual back flow preventer test was available.

The deficiency affected one of numerous required tests of the automatic sprinkler system. The automatic sprinkler system provides protection to the entire facility.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5, 1998 NFPA 25 Section 9-6.2

Buildings of Type I (332) construction must have vertical shafts constructed with a two-hour fire resistance rating.The facility failed to ensure elevator shafts were enclosed with construction having a fire resistance rating of at least two hours. Observation determined unsealed spaces around the hydraulic pipes from the Elevator Equipment Room to the elevator shaft. The hydraulic pipes ran under the corridor floor from the Elevator Equipment Room to the elevator shaft inside an approximately 12 inch diameter pipe. The area around the hydraulic pipes was not sealed with fire rated material to ensure a two-hour fire resistance rating.

Failure to ensure vertical shafts are constructed with a fire resistance rating of at least two hours increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) elevator shaft in the facility.