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NFPA 101:18.3.1 Protection of Vertical Openings. Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 18.3.1.1 through 18.3.1.8.
NFPA 101:8.6.4 Shafts. Shafts that do not extend to the bottom or the top of the building or structure shall comply with either 8.6.4.1, 8.6.4.2, or 8.6.4.3.


NFPA 101:8.6.5* Required Fire Resistance Rating. The minimum fire resistance rating for the enclosure of floor openings shall be as follows (see 7.1.3.2.1 for enclosure of exits):
(1) Enclosures connecting four or more stories in new construction - 2-hour fire barriers
(2) Other enclosures in new construction-1-hour fire barriers
(3) Existing enclosures in existing buildings - 1/2-hour fire barriers
(4) Enclosures for lodging and rooming houses - as specified in Chapter 26
(5) Enclosures for new hotels - as specified in Chapter 28
(6) Enclosures for new apartment buildings-as specified in Chapter 30


NFPA 101:8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.


NFPA 101:8.3.4.2* The fire protection rating for opening protectives in fire barriers, fire-rated smoke barriers, and fire-rated smoke partitions shall be in accordance with Table 8.3.4.2, except as otherwise permitted in 8.3.4.3 or 8.3.4.4.


Table 8.3.4.2 Minimum Fire Protection Ratings for Opening Protectives in Fire Resistance-Rated Assemblies and Fire-Rated Glazing Markings


Fire barriers Walls and Partitions (hr) Fire Door Assemblies (hr) Fire-Rated Glazing Marking Door Vision Panel
3 3 < or = to 100 in.2, D-H-180 or D-H-W-180h
2 1 ½ D-H-90 or D-H-W-90
1 ¾ D-H-45 or D-H-W-45
½ 1/3 D-20 or D-W-20


Based on visual observation the facility failed to assure that a two hour fire rated constructed enclosure surrounding the vertical opening was properly assembled to protect the occupants from a possible dangerous circumstances such as smoke or fire traveling freely vertically between floors consequently affecting the safety of all upper level occupiable floors. This reduces or eliminates the potential of fire and/or smoke spreading from one floor to another. The lack of a two hour rated constructed enclosure surrounding the vertical opening shaft creates a high risk of injury and/or death. This deficiency has the potential to affect twenty four of twenty four patients.

Findings:

During the facility tour on December 12, 2022 between the hours of 12:15 p.m. to 3:15 p.m. the Bridgestone tenant had a four story interior access stair, identified as the west wing (north) stair, that had a 45 minute labeled fire door. The stairwell door was lacking a 1 1/2 hour rated stairwell enclosure fire door.

The interview with the Facility Supervisor revealed the facility was not aware a new forty five minute fire door had been installed recently to replaced the existing ninety minute fire door in the four story interior stair identified as the west wing (north) interior stairwell.

NFPA 101:18.3.2.1* Hazardous Areas. Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 18.3.2.1 shall be protected as indicated.

Table NFPA 101:18.3.2.1 Hazardous Area Protection

Hazardous Area Description Protection/ Separation +

Boiler and fuel-fired heater rooms 1 hour
Central/bulk laundries larger than 100 ft2 (9.3 m2) 1 hour
Laboratories employing flammable or combustible materials in quantities
less than those that would be considered a severe hazard See 18.3.6.3.11.
Laboratories that use hazardous materials that would be classified as a
severe hazard in accordance with NFPA 99, Standard for Health Care Facilities 1 hour
Paint shops employing hazardous substances and materials in quantities
less than those that would be classified as a severe hazard 1 hour
Physical plant maintenance shops 1 hour
Rooms with soiled linen in volume exceeding 64 gal (242 L) 1 hour
Storage rooms larger than 50 ft2 (4.6 m2) but not exceeding
100 ft2 (9.3 m2) and storing combustible material See 18.3.6.3.11.
Storage rooms larger than 100 ft2 (9.3 m2) and storing combustible
Material 1 hour
Rooms with collected trash in volume exceeding 64 gal (242 L) 1 hour
+Minimum fire resistance rating.

NFPA 101:18.3.6.3.5 Doors shall be self-latching and provided with positive latching hardware.

NFPA 101:18.3.6.3.6 Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials shall not be required to meet the latching requirements of 18.3.6.3.5.

NFPA 101:18.3.6.3.8 Corridor doors utilizing an inactive leaf shall have automatic flush bolts on the inactive leaf to provide positive latching.

NFPA 101:18.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

NFPA 101:7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.

Based on visual observation the facility failed to maintain the separation of hazardous areas from other parts of the building, including the egress corridor. Hazardous areas within a supervised sprinklered facility are required to be constructed to resist the passage of smoke and provide a door that self closes and self-latches properly. The deficient practice had the potential to affect twenty four of twenty four patients.

Findings:

During the facility tour on December 12, 2022 between the hours of 12:15 p.m. to 3:15 p.m. the storage room approximately nine feet by ten feet lacked a labeled forty five minute fire door.


The interview with the Facility Supervisor revealed the facility was not aware that the soiled utility room greater than 50 sq. feet and less than 100 sq. feet are required to have a minimum forty five minute fire door label.

NFPA 101:18.3.7.1 Buildings containing health care facilities shall be subdivided by smoke barriers (see 18.2.4.3), unless otherwise permitted by 18.3.7.2, as follows:
(1) To divide every story used by inpatients for sleeping or treatment into not less than two smoke compartments.
(2) To divide every story having an occupant load of 50 or more persons, regardless of use, into not less than two smoke compartments
(3) To limit the size of each smoke compartment required by 18.3.7.1(1) and (2) to an area not exceeding 22,500 ft2 (2100m2), unless the area is an atrium separated in accordance with 8.6.7, in which case no limitation in size is required
(4) To limit the travel distance from any point to reach a door in the required smoke barrier to a distance not exceeding 200 ft (61 m)

NFPA 101:18.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b) Not less than two separate smoke compartments shall be provided on each floor.
(2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems.
NFPA 101:18.3.7.4 Materials and methods of construction used for required smoke barriers shall not reduce the required fire resistance rating.

NFPA 101:8.3.5.1.2 The maximum nominal diameter of the penetrating item, as indicated in 8.3.5.1.1(4)(a) through (d), shall not be greater than 4 in. (100 mm) and shall not exceed an aggregate 100 in.2 (64,520 mm2) opening in any 100 ft2 (9.3 m2) of floor or wall area.

NFPA 101:8.5.2.2 Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

NFPA 101:8.3.5 Penetrations. The provisions of 8.3.5 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations in fire walls, fire barrier walls, and fire resistance-rated horizontal assemblies. The provisions of 8.3.5 shall not apply to approved existing materials and methods of construction used to protect existing through-penetrations and existing membrane penetrations in fire walls, fire barrier walls, or fire resistance-rated horizontal assemblies, unless otherwise required by Chapters 11 through 43.

NFPA 101: 8.3.5.1 Firestop Systems and Devices Required. Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through- Penetration Firestops, at a minimum positive pressure differential of 0.01 in. water column (2.5 N/m2) between the exposed and the unexposed surface of the test assembly.

NFPA 101:8.3.5.1.1 The requirements of 8.3.5.1 shall not apply where otherwise permitted by any one of the following:
(1) Where penetrations are tested and installed as part of an assembly tested and rated in accordance with ASTM E 119, Standard Test Methods for Fire Tests of Building Construction and Materials, or ANSI/UL 263, Standard for Fire Tests of Building Construction and Materials
(2) Where penetrations through floors are enclosed in a shaft enclosure designed as a fire barrier
(3) Where concrete, grout, or mortar has been used to fill the annular spaces around cast-iron, copper, or steel piping that penetrates one or more concrete or masonry fire resistance- rated assemblies and both of the following criteria are also met:
(a) The nominal diameter of each penetrating item shall not exceed 6 in. (150 mm), and the opening size shall not exceed 1 ft2 (0.09 m2).
(b) The thickness of the concrete, grout, or mortar shall be the full thickness of the assembly.

Based on visual observation, the facility failed to maintain the space between the penetrating item and the smoke barrier. The penetrating item must be properly filled with a material (intumescent) that is capable of maintaining the fire resistance rating in accordance with ASTM E-814 or UL1479 designed for wall cable, wire type penetrations of the smoke barrier. Unprotected penetrations would permit the movement of smoke / fire from one compartment to the other in the facility. The deficient practice had the potential to affect twenty four of twenty four patients.

Findings:

During the facility tour on December 12, 2022 between the hours of 12:15 p.m. to 3:15 p.m. the smoke barrier separating the Bridgestone Continuing Care tenant space from the hospital had several penetrations above the ceiling in the corridor area was lacking the proper intumescent fire stopping material at the head of wall and several penetrations.

The interview with the Facility Supervisor revealed the facility was not aware that the smoke barrier had penetrations and the top of the smoke barrier in the corridor that lacked the proper one hour fire rated intumescent.

NFPA 101:18.3.7.6* Doors in smoke barriers shall be substantial doors, such as 13?4 in. (44 mm) thick, solid-bonded wood-core doors, or shall be of construction that resists fire for a minimum of 20 minutes, and shall meet the following requirements:
(1) Nonrated factory- or field-applied protective plates, unlimited in height, shall be permitted.
(2) Cross-corridor openings in smoke barriers shall be protected by a pair of swinging doors or a horizontal-sliding door complying with 7.2.1.14, unless otherwise permitted by 18.3.7.7.
(3) The swinging doors addressed by 18.3.7.6(2) shall be arranged so that each door swings in a direction opposite from the other.
(4) The minimum clear width for swinging doors shall be as follows:
(a) Hospitals and nursing homes - 411?2 in. (1055 mm)
(b) Psychiatric hospitals and limited care facilities - 32 in. (810 mm)
(5) The minimum clear width opening for horizontal-sliding doors shall be as follows:
(a) Hospitals and nursing homes-6 ft 11 in. (2110 mm)
(b) Psychiatric hospitals and limited care facilities - 64 in. (1625 mm)
(6) The clearance under the bottom of smoke barrier doors shall not exceed 3?4 in. (19 mm).

NFPA 80:5.5.7 When holes are left in a door or frame due to changes or removal of hardware or plant-ons, the holes shall be repaired by the following methods:
(1) Install steel fasteners that completely fill the holes
(2) Fill the screw or bolt holes with the same material as the door or frame

Based on visual observation the facility failed to assure that installed smoke barrier doors provide the minimum required clear width of 32 inches for each door leaf of the smoke barrier cross corridor double door. Doors installed for a particular purpose offers a barrier that restricts the movement of smoke from one compartment to another. The deficient practice has the potential to affect twenty four of twenty four patients. There was one smoke barrier with two sets of cross corridor door double doors that were deficient.

Findings:

During the facility tour on December 12, 2022 between the hours of 12:15 p.m. to 3:15 p.m. the two sets of corridor smoke barrier doors separating the Bridgestone tenant space from the rest of the hospital had several holes in the door that lacked a steel fastener.

The interview with the Facility Supervisor revealed the facility was not aware of the cross corridor smoke barrier double doors had open holes that did not meet the minimum requirements of NFPA 80.