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Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that; corridors were separated from use areas by required construction, fire barrier having at least a two-hour fire resistance rating was constructed of materials as required with regards to fire dampers in duct work, building construction type and height met the requirement for health care occupancies limited to specific types of building construction, corridor walls formed a barrier to limit the transfer of smoke and that such walls are permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke, that atriums were used in accordance with 8.2.5.6., hazardous areas were protected in accordance with 8.4, that exit access was arranged so that exits are readily accessible at all times in accordance with section 7.1., that heating, ventilating, and air conditioning comply with the provisions of section 9.2 and were installed in accordance with the manufacturer's specifications with regards to dampers and chutes for trash and linen were installed so they could be used only by authorized personnel.

The cumulative affect of these systemic practices resulted in the facility failure to ensure the health and safety of the patients would be met.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure the hospital met the applicable provisions of the Life Safety Code of the National Fire Protection Association. The facility was located at two addresses with Building 1 having a census of 18 patients at the time of the survey and Building 2 with a census of 39 patients at the time of the survey. Potentially all persons utilizing the facility could be affected.

Findings include:

On 10/16/12 between 1:40 P.M. and 3:45 P.M., tour of Building 1 was conducted with Staff AA and AB. Tour of the facility revealed it was located on the seventh floor of another healthcare facility and was divided into two units identified as 7A and 7B. The north wing of Unit 7A contained the administrative offices and larger storage areas. The south wing of 7A contained the special care unit.

The following life safety code deficiencies were observed in Building 1:

K17, addressed the facility failure to ensure that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating in non-sprinklered buildings where walls properly extend above the ceiling.
K29 addressed the facility failure to ensure that one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas.

Building 2 occupied the second and partial third floors of another health care occupancy. The third floor was identified as the special care unit where patients required more intensive care. On 10/17/12 between 1:40 P.M. and 3:20 P.M. and on 10/18/12 between 8:30 A.M. and 10:45 A.M. tour of Building 2 was conducted with Staff AA. The following life safety code deficiencies were observed in Building 2:

K11 addressed the facility failure to ensure that if the building had a common wall with a nonconforming building, the common wall is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required with regards to fire dampers in duct work.
K12 addressed the facility failure to ensure that building construction type and height met the requirement for health care occupancies limited to specific types of building construction.
K17 addressed the facility failure to ensure that corridor walls formed a barrier to limit the transfer of smoke. Such walls are permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.
K20 addressed the facility failure to ensure that atriums were used in accordance with 8.2.5.6.
K29 addressed the facility failure to ensure that hazardous areas were protected in accordance with 8.4, regarding protection provided with automatic extinguishing systems without fire-resistive separation; the space protected shall be enclosed with smoke partitions in accordance with 8.2.4. Doors were to be self-closing or automatic closing in accordance with 7.2.1.8.
K38 addressed the facility failure to ensure that exit access was arranged so that exits are readily accessible at all times in accordance with section 7.1.
K67 addressed the facility failure to ensure that heating, ventilating, and air conditioning comply with the provisions of section 9.2 and were installed in accordance with the manufacturer's specifications with regards to dampers.
K71 addressed the facility failure to ensure that trash or linen gravity chutes were installed as a limited access gravity chute by installing a key in either the chute intake door or the entry door into the service room. Limited access waste chutes were to be installed so that they could be used only by authorized personnel.

Please see the life safety code report for more specific details.