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Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls as evidenced by an unsealed penetration. The penetration could result in the reduction in the facility's staff ability to protect in place and increase the risk of injury to the patients due to smoke and fire. This affected 2 of 2 smoke compartments.

NFPA 101, Life Safety Code (2000 Edition)
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Fire Chief, Firefighter 1, Firefighter 2, and Chief of Plant Operations 1 on 8/6/13, the smoke barrier walls were observed

At 3:00 p.m., there was a 3/4 inch unsealed conduit pipe in the smoke barrier wall above the attic access panel near the nursing station.

Based on observation, the facility failed to maintain its smoke barrier doors to continuously serve as a smoke barrier to prevent the spread of smoke and fire. This was evidenced by a smoke barrier door that was equipped with latching hardware and failed to latch. This affected 2 of 2 smoke compartments within the facility and could result in the spread of smoke and fire.

Findings:

During fire alarm testing with the Fire Chief, Firefighter 1, Firefighter 2, and Chief of Plant Operations 1 on 8/6/13, the smoke barrier doors were observed.

1. At 12:06 p.m., the east smoke barrier door in the 101 corridor was not latching when tested. Two attempts were made.

Based on observation and interview, the facility failed to maintain their emergency lighting units. This was evidenced by an emergency lighting unit with a disconnected test button. This affected 1 of 2 smoke compartments, and could result in a dimly lit egress path due to limited visibility in the event of a power failure.

NFPA 101 Life Safety Code, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with the Fire Chief, Firefighter 1, Firefighter 2, and Chief of Plant Operations 1 on 8/6/13, the emergency lighting units were tested and a staff person was interviewed.

1. At 12:14 p.m., the emergency lighting unit outside of room 120 was unable to be tested as the test button was not illuminated. The button was pressed and the lighting unit did not go into a test mode (one bulb lite).

2. At 12:15 p.m., the Chief of Plant Operations 1 said during an interview that the test button should be illuminated. The test button was pressed and it appeared to be disconnected.

Based on observation, the facility failed to maintain the electrical panels as evidenced by unidentified circuit breaker. This could result in a delay to turn off a circuit breaker in the event of an electrical fire. This affected 1 of 2 smoke compartments.

NFPA 70, National Electrical Code, 1999 Edition
384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer ' s name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or board.

Findings:

During a tour of the facility with the Fire Chief, Firefighter 1, Firefighter 2, and Chief of Plant Operations 1 on 8/6/13, the facility electrical system was observed and a staff person was interviewed.

At 11:43 a.m., there was 1 of 31 circuits in electrical panel A in Room 103A that was not identified. Circuit 18 was in the on position and not identified to it's purpose.

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by the mounting of an alcohol based hand rub dispenser over an ignition source. This affected 1 of 2 smoke compartments, and could result in an alcohol based hand rub ignited fire.

Findings:

During a tour of the facility with the Fire Chief, Firefighter 1, Firefighter 2, and Chief of Plant Operations 1 on 8/6/13, the alcohol based hand rub dispensers in the facility were observed.

At 11:16 a.m., there was an alcohol based hand rub dispenser that contained sixty-two percent ethyl alcohol by volume mounted above a light switch in room 110 (Soiled Linen Room).