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1200 CENTRE STREET

BOSTON, MA null

Egress Doors

Tag No.: K0222

Based on observations and staff interview the facility failed to ensure compliance with the 2012 edition of NFPA 101 Life Safety Code.

-Chapter 4 section 4.5.8 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance.

-Chapter 19 section 19.2.2.2.4 states doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following:

(1) Locks complying with 19.2.2.2.5 shall be permitted.
(2)*Delayed-egress locks complying with 7.2.1.6.1 shall be permitted.
(3)*Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.
(4) Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted.
(5) Approved existing door-locking installations shall be permitted.

-Chapter 7 section 7.2.1.6.1.1 states approved, listed, delayed-egress locking systems
shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection
system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided
that all of the following criteria are met:

(1) The door leaves shall unlock in the direction of egress upon actuation of one of the following:

(a) Approved, supervised automatic sprinkler system in accordance with Section 9.7
(b) Not more than one heat detector of an approved, supervised automatic fire detection system in accordance with Section 9.6
(c) Not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6
(2) The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism.
(3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions:
(a) The force shall not be required to exceed 15 lbf (67 N).
(b) The force shall not be required to be continuously applied for more than 3 seconds.
(c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening.
(d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
(4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1.8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows
shall be located on the door leaf adjacent to the release device in the direction of egress:
PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS
(5) The egress side of doors equipped with delayed-egress locks shall be provided with emergency lighting in accordance with Section 7.9.

Findings Include:

While conducting the facility tour during the afternoon hours of 03/14/22, and morning hours of 03/15/22 observations revealed that the delayed egress locking device installed on the building exit doors, did not provide a signs for releasing the exit door, PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS.
There are 20 out of 21 doors with a delay egress locking device, and none of the 20 doors had signs for how to release the exit doors.
Notre: The 21st door did have a delay locking device but at the time of this survey but was not activated. The door opened freely without a delayed lock

As a result of the finding the facility failed to ensure compliance with NFPA 101 Chapter 7 section 7.2.1.6.1.1

As a result of the findings to ensure that exit egress door are maintain and open in case of an emergency, a undetermined number of facility residents, staff and visitors may have been and may continue to be affected by the deficiency.

The finding was confirmed by the Administrator, Director of Facility's and the Director of Security during the exit conference.

Horizontal Exits

Tag No.: K0226

This Standard is not met as evidenced by:

Based on observations and confirmed by the Director of Facilities during the building tour, the facility failed to ensure that horizontal exit doors are maintained as required.

Section 19.2.2.5 states horizontal exits complying with 7.2.4 and the modifications of 19.2.2.5.1 through 19.2.2.5.4 shall be permitted.

Section 7.2.1.15.2 states 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.

Section 7.2.4.3.1 states fire barriers separating buildings or areas between which there are horizontal exits shall have a minimum 2-hour fire resistance rating, unless otherwise provided in 7.2.4.4.1, and shall provide a separation that is continuous to the finished ground level.

NFPA 80 section 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

Section 6.3.1.7.1 states the clearances between the top and vertical edges of the door and the frame, and the meeting edges of doors swinging in pairs, shall be 1/8" + 1/16" (3.18 mm + 1.59 mm) for steel doors and shall not exceed 1/8" (3.18 mm) for wood doors.

Section 6.3.1.7.2 states clearances shall be measured from the pull face of the door(s).

Section 6.4.4.4.1 states where permitted by the AHJ, pairs of doors not provided with an astragal shall be permitted to have labeled fire exit hardware and an open back strike installed on the inactive leaf, and either labeled fire exit hardware or any labeled latch capable of being opened by one obvious operation from the egress side
installed on the active leaf.

Section 6.4.7.1 states doors swinging in pairs, where located within a means of egress, shall not be equipped with astragals that inhibit the free use of either leaf.

Section 6.4.7.2 states pairs of doors that require astragals shall have at least one attached in place to project approximately 3/4" (19 mm) or as otherwise indicated in the individual published listings.

THE FINDINGS INCLUDE:

During the morning hours of 03/15/22 while touring the 3rd floor level, the West side bridge door was tested for operation. This pair of steel doors were observed to have a gap in excess of 1/4" between the two door leaves.

This deficient practice could affect all patients, staff, and visitors in the event a fire/smoke were to develop in this location.

As a result the facility failed to comply with section 19.2.2.5 and applicable codes requiring horizontal exit doors to comply with NFPA 80.

This was confirmed with the Director of Facilities during the exit interview process.

Suite Separation, Hazardous Content, and Subd

Tag No.: K0255

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, suites are not separated as required. This deficient practice could affect all patients, staff and visitors within the improperly separated suite.

Section 19.2.5.7.1.2 states suites shall be separated from the remainder of the building, and from other suites, by one
of the following:
(1) Walls and doors meeting the requirements of 19.3.6.2 through 19.3.6.5
(2) Existing approved barriers and doors that limit the transfer of smoke

Section 19.3.6.2.1 states 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, unless otherwise permitted by 19.3.6.2.4 through 19.3.6.2.8.

Section 19.3.6.2.2 states corridor walls shall have a minimum 1/2-hour fire resistance rating.

Section 19.3.6.2.3 states corridor walls shall form a barrier to limit the transfer of smoke.

Section 19.3.6.2.4 states in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, 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.

Section 19.3.6.2.5 states existing corridor partitions shall be permitted to terminate at ceilings that are not an integral part of a floor construction if 60 in. (1525 mm) or more of space exists between the top of the ceiling subsystem and the bottom of the floor or roof above, provided that all the following criteria are met:
(1) The ceiling is part of a fire-rated assembly tested to have a minimum 1-hour fire resistance rating in compliance with the provisions of Section 8.3.
(2) The corridor partitions form smoke-tight joints with the ceilings, and joint filler, if used, is noncombustible.
(3) Each compartment of interstitial space that constitutes a separate smoke area is vented, in a smoke emergency, to
the outside by mechanical means having the capacity to provide not less than two air changes per hour but, in no case, a capacity less than 5000 ft3/min (2.35 m3/s).
(4) The interstitial space is not used for storage.
(5) The space is not used as a plenum for supply, exhaust, or return air, except as noted in 19.3.6.2.5(3).

Section 19.3.6.3.4 states a clearance between the bottom of the door and the floor covering not exceeding 1 in. (25 mm) shall be permitted for corridor doors.

Findings Include:

During the afternoon hours of 03/15/22 while touring the B2 floor level of the Berger Building, the area adjacent to the center stair and elevator corridor, was observed as not having the required windows/walls to limit the transfer of smoke. The Biohazard Office area has windows and partitions constructed with an open four inch (4") void at the meeting edge of the partition and the window's casing/apron.

In addition, the removal of the suite corridor wall and door has opened the Biohazard Office to the corridor.

As a result, the facility failed to comply with section 19.3.6.2.3 to limit the transfer of smoke in corridor walls.

This was reviewed with and acknowledged by the Hospital's Environmental Director and LSC staff during the exit interview process who indicated that re-installing the corridor wall and door adjacent to the Center stair would re-establish the suite.

Hazardous Areas - Enclosure

Tag No.: K0321

Based on observations the facility failed to ensure that all hazardous areas are protected in accordance with the 2012 edition of NFPA 101 Life Safety Code. This has a potential to affect an indeterminable number of facility residents,staff and visitors throughout the building.

-Chapter 19 Section 19.3.2.1 states any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.

-Chapter 19 Section 19.3.2.1.1 states an automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9.

-Chapter 19 Section 19.3.2.1.2* states where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

-Chapter 19 Section 19.3.2.1.3 states the doors shall be self-closing or automatic-closing.

-Chapter 19 Section 19.3.2.1.5 states hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Findings Include:

While conducting the facility tour during the morning hours of 03/15/22 observations revealed that some doors to the sprinklered hazardous rooms failed to be smoke tight.
The following hazardous rooms were found not to be smoke tight.

1) The Central Supply Storage room which has doors that have self closing device was bing held open with non-approved devices.
The two (2) mian corridor doors to Central Supply was being held open with a wooden wedges, and the rear door was being held open with a 5 gallon bucket.

2) The 3rd floor, Main Electrical Room behind Elevator Bank, had a open electrical box wall penetration in 2 hour fire rated assembly.

As a result of the finding the facility is found to be non-compliant with Chapter 19 Section 19.3.2.1.

As a result of the findings to ensure that hazardous room are maintain to reduce the spread of smoke, a undetermined number of facility residents, staff and visitors may have been and may continue to be affected by the deficiency.
.
The finding was confirmed by the Administrator, Director of Facility's and the Director of Security during the exit conference.

Cooking Facilities

Tag No.: K0324

Based on observations and confirmed by staff interview the facility to ensure compliancy with Chapter 19 of the 2012 edition of NFPA 101 "Life Safety Code". Chapter 19 "Existing Health Care Occupancies" Section 19.3.2.5.1 states cooking facilities shall be protected in accordance
with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3,
or 19.3.2.5.4.
Chapter 19 Section 19.3.2.5.3* states that within a smoke compartment, where residential or commercial cooking equipment is used to prepare meals
for 30 or fewer persons, one cooking facility shall be permitted
to be open to the corridor, provided that all of the following
conditions are met:
(1) The portion of the health care facility served by the cooking
facility is limited to 30 beds and is separated from other
portions of the health care facility by a smoke barrier constructed
in accordance with 19.3.7.3, 19.3.7.6, and 19.3.7.8.
(2) The cooktop or range is equipped with a range hood of a
width at least equal to the width of the cooking surface,
with grease baffles or other grease-collecting and cleanout
capability.
(3)*The hood systems have a minimum airflow of 500 cfm
(14,000 L/min).
(4) The hood systems that are not ducted to the exterior additionally
have a charcoal filter to remove smoke and odor.
(5) The cooktop or range complies with all of the following:
(a) The cooktop or range is protected with a fire suppression
system listed in accordance with UL 300,
Standard for Fire Testing of Fire Extinguishing Systems for
Protection of Commercial Cooking Equipment, or is tested
and meets all requirements of UL 300A, Extinguishing
System Units for Residential Range Top Cooking Surfaces,
in accordance with the applicable testing document ' s
scope.
(b) A manual release of the extinguishing system is provided
in accordance with NFPA 96, Standard for Ventilation
Control and Fire Protection of Commercial Cooking
Operations, Section 10.5.
(c) An interlock is provided to turn off all sources of
fuel and electrical power to the cooktop or range
when the suppression system is activated.
(6)*The use of solid fuel for cooking is prohibited.
(7)*Deep-fat frying is prohibited.
(8) Portable fire extinguishers in accordance with NFPA 96
are located in all kitchen areas.
(9)*A switch meeting all of the following is provided:
(a) A locked switch, or a switch located in a restricted
location, is provided within the cooking facility that
deactivates the cooktop or range.
(b) The switch is used to deactivate the cooktop or
range whenever the kitchen is not under staff supervision.
(c) The switch is on a timer, not exceeding a 120-minute
capacity, that automatically deactivates the cooktop
or range, independent of staff action.
(10) Procedures for the use, inspection, testing, and maintenance
of the cooking equipment are in accordance with
Chapter 11 of NFPA 96 and the manufacturer ' s instructions
and are followed.
(11)*Not less than two AC-powered photoelectric smoke alarms,
interconnected in accordance with 9.6.2.10.3, equipped
with a silence feature, and in accordance with NFPA 72,
National Fire Alarm and Signaling Code, are located not closer
than 20 ft (6.1 m) from the cooktop or range.
(12) No smoke detector is located less than 20 ft (6.1 m) from
the cooktop or range.
(13) The smoke compartment is protected throughout by an
approved, supervised automatic sprinkler system in accordance
with Section 9.7.

Findings Include:

While conducting a facility tour during the afternoon hours of 03/15/22 observations revealed the following. The Health Center Building consists of twelve (12) separate fourteen (14) bed nursing neighborhood units, six located on the second and six located on the third floor. All twelve (12) units contain cooking facilities located within a smoke compartment that is open to the corridor and used for the preparation of meals for a population of less than thirty (30) persons. A check of the required conditions included in Section 19.3.2.5.3 revealed that the facility had failed to maintain the Extinguishing System Units for Residential Range Top Cooking Surfaces, in accordance with the applicable testing documents scope.
The Extinguishing System Unit for neighborhood unit 3rd floor south (labeled "Birch") was found not to be fully charged. The gauge on the Extinguishing System Unit showed that the unit was in the charged mode.

As a result of the finding the facility is found to be non-compliant with Chapter 19 Section 19.3.2.5.3.

As a result of the failing to ensure that Extinguishing System Units for Residential Range Top Cooking Surfaces are maintained to reduce the spread of fire, a undetermined number of facility residents, staff and visitors may have been and may continue to be affected by the deficiency.

The finding was confirmed by the Administrator, Director of Facility's and the Director of Security during the exit conference.

Corridor - Doors

Tag No.: K0363

This Standard is not met as evidenced by:

Based on observations and confirmed by the Director of Facilities during the building tour, the facility failed to ensure that patient bedroom doors are installed as required.

Section 18.3.6.3.1 states doors protecting corridor openings shall be constructed to resist the passage of smoke, and the following also shall apply:
(1) Compliance with NFPA80, Standard for Fire Doors and Other Opening Protectives, shall not be required.
(2) Clearance between the bottom of the door and the floor covering not exceeding 1 in. (25 mm) shall be permitted
for corridor doors.
(3) Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain
flammable or combustible material shall not be required to be constructed to resist the passage of smoke.

Section 7.2.1.5.1 states door leaves shall be arranged to be opened readily from the egress side whenever the building is occupied.

THE FINDINGS INCLUDE:

During the morning hours of 03/14/22 while touring the newly reconstructed 6th floor, the following items were observed regarding corridor doors:

1) The patient bedroom doors were checked for structural integrity and proper operation. At this time, it was observed that the bedroom doors consist of two separate door leaves. There is a 36" active leaf and a 12" inactive leaf provided at each bedroom door location. When the doors were closed, a gap ranging from 1/8" to 1/4" was observed at every bedroom door location between the two door leaves on this entire floor level.

2) The sliding/rolling doors to each of the Multi Purpose Rooms (2) and Family Rooms (2) were observed as having no hardware to open and/or close the doors. As a result, it is not readily apparent how to exit the room when the door is closed.

These deficient practices could affect all patients, staff, and visitors in each of the three zones if a fire/smoke were to develop in any location of this floor level.

As a result the facility failed to comply with section 18.3.6.3.1 requiring corridor doors to resist the passage of smoke.

This was confirmed with the Director of Facilities during the exit interview process.

Smoke Barrier Door Glazing

Tag No.: K0379

This Standard is not met as evidenced by:

Based on observations and confirmed by the Director of Facilities during the building tour, the facility failed to ensure that smoke barrier doors are constructed and installed as required.

Section 18.3.7.8 states doors in smoke barriers shall comply with 8.5.4 and all of the following:
(1) The doors shall be self-closing or automatic-closing in accordance with 18.2.2.2.7.
(2) Latching hardware shall not be required.
(3) Stops shall be required at the head and sides of door frames.
(4) Rabbets, bevels, or astragals shall be required at the meeting edges of pairs of doors.
(5) Center mullions shall be prohibited.

Section 18.3.7.9 states vision panels consisting of fire-rated glazing in approved frames shall be provided in each cross-corridor swinging door and at each cross-corridor horizontal-sliding door in a smoke barrier.

Section 18.3.7.10 states vision panels in doors in smoke barriers, if provided, shall be of fire-rated glazing in approved frames.

THE FINDINGS INCLUDE:

During the morning hours of 03/14/22 while touring the newly reconstructed 6th floor, the smoke barrier doors were checked for structural integrity and proper operation. At this time, it was observed that the smoke barrier doors are not equipped with the required vision panels. In addition, the doors were observed as having no rabbet, bevel, or astragal to ensure the proper joint to limit the transfer of smoke.
Note: This deficiency applies to the three (3) sets of cross corridor smoke barrier doors.

This deficient practice could affect all patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where movement from one smoke compartment to another must be performed as well as limiting the transfer of smoke.

As a result, the facility failed to comply with section 18.3.7.8 and 18.3.7.9 requiring smoke barrier doors to have vision panels and be smoke tight.

This was confirmed with the Director of Facilities during the exit interview process.

Utilities - Gas and Electric

Tag No.: K0511

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, heat producing devices are not stored as required. This deficient practice could affect all patients, staff and visitors within the improperly separated suite.

NFPA 101, Section 19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

Section 19.5.1.2, existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.

Section 19.5.2.1, states that heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ' s specifications, unless otherwise modified by 19.5.2.2.

Section 19.5.2.2 states that any heating device, other than a central heating plant, shall be designed and installed so that combustible material cannot be ignited by the device or its appurtenances, and the following requirements also shall apply:
(1) If fuel-fired, such heating devices shall comply with the following:
(a) They shall be chimney connected or vent connected.
(b) They shall take air for combustion directly from the outside.
(c) They shall be designed and installed to provide for complete separation of the combustion system from
the atmosphere of the occupied area.

(2) Any heating device shall have safety features to immediately stop the flow of fuel and shut down the equipment in
case of either excessive temperature or ignition failure.

Section 9.2.2, states that ventilating or heat-producing equipment shall be in accordance with NFPA 91, Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Noncombustible Particulate Solids; NFPA 211, Standard for Chimneys, Fireplaces, Vents, and Solid Fuel-Burning Appliances; NFPA 31, Standard for the Installation of Oil-Burning Equipment; NFPA 54, National Fuel Gas Code; or NFPA 70, National Electrical Code, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service.

Findings Include:

During the afternoon hours of 03/15/22 while touring the B 1 floor level, Main Kitchen of the Berenson Building, it was noted that a 20 lb. propane cylinder with an attached 8 feet long hose and torch were stored on kitchen floor, adjacent to bread trays.

The heat producing device was:
1. Neither chimney connected or vent connected.
2. Not designed nor installed to provide for complete separation of the combustion system from
the atmosphere of the occupied area.
3. Nor did the device have any safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperature or ignition failure.

As a result, the facility failed to comply with Section 19.5.2.1 or Section 19.5.2.2.

This was reviewed with and acknowledged by the Hospital's Environmental Director and LSC staff during the exit interview process who indicated that propane tank and assembly were removed immediately upon discovery of it's presence in the kitchen.

HVAC

Tag No.: K0521

This Standard is not met as evidenced by:

Based on observations and confirmed by the Director of Facilities during the building tour, the facility failed to ensure that the Heating Ventilation Air Conditioning (HVAC) System is installed as required. Section 19.5.2.1 states heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications, unless otherwise modified by 19.5.2.2.

Section 9.2.1 states Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 90A section 5.3.1.1 states an approved fire damper shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.

NFPA 90A section 4.3.5.1 states a service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, combination fire/smoke damper, and any smoke detectors that need access for installation, cleaning, maintenance, inspection, and testing.

Section 4.3.5.1.1 states the opening shall be large enough to permit maintenance and resetting of the device.

Section 4.3.5.2 states service openings shall be identified with letters having a minimum height of 12.7 mm (1/2") to indicate the location of the fire protection device(s) within.

THE FINDINGS INCLUDE:

During the afternoon hours of 03/15/22 while viewing the 2-hour fire separation wall on 4th floor level, various HVAC ducts were observed as penetrating the wall. Upon closer examination, a total of three (3) HVAC ducts were observed, one duct in plain view, and the two others located in corridor ceiling soffits.
None of these HVAC ducts observed were equipped with access panels to determine if fire dampers were installed in the duct work as required. This identical situation was observed as deficient on the 1st, 2nd, 3rd, and 4th floor levels as all floors were constructed identical. However, the 5th floor is under major reconstruction (non-occupied) and all existing duct work has been disconnected.

Note 1: The 6th floor level was recently reconstructed and surveyed under chapter 18 for a New Healthcare Occupancy. As this floor was fully sprinklered at this time of reconstruction, the 2-hour wall was reduced to a 1-hour smoke barrier wall not requiring fire dampers.

Note 2: A total of one fire damper was in fact viewable, located on the 4th floor level adjacent to the Dining Room in the corridor ceiling soffit.

As a result, the facility failed to comply with NFPA 90A section 4.3.5.1 requiring service openings to ensure fire dampers are provided and able to be maintained as required.

This deficient practice could affect all patients, as well as an undetermined amount of staff and visitors on each of these floor levels in the event of an actual emergency situation.

As a result, the facility failed to comply with NFPA 90 section 4.3.5.1 requiring fire dampers and access panels for required maintenance and testing.

This was confirmed with the Director of Facilities during the exit interview process.