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1.The facility did not ensure that cooking facilities open to the corridor within smoke compartments are protected as required by NFPA 101 chapter 19 section 19.3.2.5.3 sections (1) - (13).

a.On 01/09/19 at 10:00 AM, while touring the Transitional Unit it was observed that the facility had a residential type electric range in an alcove of the facility open to the corridor and the stove was not in compliance with the requirements for cooking facilities open to the corridor as required by NFPA 101 Life Safety Code chapter 19 section 19.3.2.5.3 sections (1) - (13) i.e. lacked a fire suppression system, range hood and ventilation system covering all cooking appliances, a lock out system for power, that was also connected to timer that doesn't exceed 120 minutes, a manual release for a suppression system and interlock to secure power upon activation of the suppression system subsequent interview of the Manager of Therapeutic Recreation identified it was used for training patients to cook and bake. The Stove was removed from the unit after the interview by engineering staff.
b. On 01/09/19 at 11:00 AM, while touring the NBU 3 it was observed that the facility had a residential type electric range in an area open to the corridor and the stove was not in compliance with the requirements for cooking facilities open to the corridor as required by NFPA 101 Life Safety Code chapter 19 section 19.3.2.5.3 sections (1) - (13) i.e. lacked a fire suppression system, range hood and ventilation system covering all cooking appliances, a lock out system for power, that was also connected to timer that doesn't exceed 120 minutes, a manual release for a suppression system and interlock to secure power upon activation of the suppression system. Subsequent interview of the Director of Engineering and Plant Operations identified going forward the stove will not be utilized and will probally be removed.

The facility did not ensure doors protecting corridor openings are substantial doors capable of resisting the passage of smoke and are provided with a means suitable for keeping the door closed. 19.3.6.3

On 01/09/19 at 11:00 AM, while touring the NBU it was observed that the patient room 1838 had cut outs at the top of the two corridor doors for the patient room for a barrier free lift that made the door not resistant to the passage of smoke and fire.