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Based on observation and interview, the facility did not enclose hazardous rooms with rated doors. This deficiency occurred in 1 of the 4 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On March 4, 2014 at 10:32 am and on April 21, 2014 at 3:30 pm, observation revealed on the 1st floor in the Pharmacy, that the door in the hazard enclosure 1 hour fire rated wall could not be verified of having at least a 45 minute rating. The door between the pharmacy and pharmacy office is only rated to 20 minutes instead of the required 45 minutes. This observed situation was not compliant with NFPA 101 (2000 ed.), section 18.3.2.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Maintenance Supervisor).
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K130
Item #1
NFPA 101 (2000 edition) section 39.3.2.1: "Protection for Hazards. Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that included woodworking and painting areas shall be protected in accordance with Section 8.4
8.4.1.1. Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42."

Based on observation and interview, the facility failed to properly protect the basement and main office which are hazardous areas from the rest of the building. This deficient practice could affect all patients, staff, and visitors in the building.

FINDINGS INCLUDE:
1) On 03/04/2014 at 1:30 pm, observation revealed that the basement contained 3 operational gas fired furnaces and 1 hot gas fired hot water heater. In addition, medical records and other combustible storage are common to this equipment within this basement. The basement is considered a hazardous area. The building did not have sprinkler protection and the ceiling of the basement was not one hour fire protection rated. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance), and staff P (Maintenance Supervisor).

2) On 3/4/2014 at 1:45 pm and on April 21, 2014 at 4:00 pm, observation revealed that the Main office area has medical record storage above that typically found in an office environment, and hence creates a hazardous room. The building did not have sprinkler protection and the walls (opening and doors) of the room were not one hour fire rated protected. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Maintenance), and staff P (Maintenance Supervisor).

Item #2
NFPA 101 (2000 edition) section 7.1.3.2.1: "Exits - Where this code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following
(a) The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less... "

Based on observation and interview, the facility failed to properly protect the north stair well out of the basement. This deficient practice could affect all staff and visitors in the basement.

FINDINGS INCLUDE:
On 03/04/2014 at 2:30 pm and on April 21, 2014 at 4:00 pm, observation revealed that the door and door frame of the exit enclosure (part of the former exterior south wall of the building) was not rated to 3/4 hour fire rated construction. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Maintenance Supervisor).

North Clinic

Item #1
NFPA 101 (2000 edition), section 39.3.2.1: "Protection for Hazards. Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that included woodworking and painting areas shall be protected in accordance with Section 8.4.
8.4.1.1 Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42."

Based on observation and interview, the facility failed to properly protect the furnace room and storage areas in the basement which are hazardous areas. This deficient practice could affect all patients, staff, and visitors in the building.
FINDINGS INCLUDE:
1. On 03/04/2014 at 2:30 pm and on April 21, 2014 at 3:49 pm, observation revealed that the walls and ceilings surrounding the furnaces and storage rooms were not rated to one hour rated enclosures nor was the area sprinkler protected. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Maintenance Supervisor).



Item #3
NFPA 101, 2000 edition, section 39.2.5.3: "Common paths of travel shall not exceed 75 feet."

Based on observation and interview, the facility failed to properly maintain the common path of travel under 75 feet.
FINDINGS INCLUDE:
On 03/04/20114, at 2:45 pm and on April 21, 2014 at 3:46 pm, observation revealed that in the basement, the common path of travel to the exit from the back of the training room to an exit was approximately 104 feet. The condition was confirmed at the time of discovery by a concurrent observation and interview with and staff P (Maintenance Supervisor).

Item #4
NFPA 101 (2000 edition) section 7.1.3.2.1 Exits: "Where this code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following:
(a) The separation shall have not less than a 1-hour fire resistance rating where the exit connects three stories or less... "

Based on observation and interview, the facility failed to properly protect the central stair out of the basement. This deficient practice could affect all staff and visitors in the basement.
FINDINGS INCLUDE:
On 03/04/2014 at 3:00 pm and on April 21, 2014 at 3:45 pm, observation revealed that the walls of the exit enclosure out of the basement, were not built to one hour fire rated construction. The doors were also not fire rated opening protective systems. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff P (Maintenance Supervisor).