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Based on observation the facility failed to provide corridors that are separate from all other areas as per NFPA 101 (Life Safety Code) for 2 of 9 corridors. This deficiency affects 10 patients in the facility.

Note: NFPA 101, 2000 Edition:

NFPA 101, Chapter 19, "Corridor" 19.3.6.1, Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5.

Findings:

During a tour of the facility conducted from February 4 through February 5, 2010, the following areas were observed to be open to the without being separated from the corridor by a smoke resistive partition. Areas maybe open to the corridor, if the area meets the at least one of the exceptions allowed by this code.

1. The admitting desk area in the Emergency Department is open to the corridor.
2. The admitting and cashier desks in the Business Office are open to the corridor.

Based on observation the facility failed to provide smoke barrier doors that were self-closing or automatic-closing for 1 of 4 smoke barrier doors on this floor. The door to the West smoke barrier wall was observed not to be self-closing or automatic-closing. This deficiency affects 8 of 98 patients in the facility.

NFPA 101:19.3.7 Subdivision of Building Spaces
19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Positive latching hardware shall not be required.

Findings:

During a tour of the facility conducted from February 3 through February 4, 2010, observation revealed that not all smoke barrier doors were closing properly. The smoke barrier door (SB43) on the 6th floor did not close when tested. The door was dragging on the flooring preventing it from closing all the way.

Based on observation the facility failed to provide proper protection to all hazardous areas. Hazardous areas shall be constructed of at least one hour fire resistance rated walls and forty-five minute fire rated doors. The door to these rooms shall be self-closing. The door to 1 of 10 hazardous areas on this floor was not closing completely. This deficiency affects 14 patients in the facility

Findings:

During a tour of the facility conducted from February 4 through February 5, 2010, observation revealed that the door to the Soiled Linen room by room 270 was not closing completely. A screw in the latch assembly was catching on the strike plate preventing the door from closing all the way.

Based on observation the facility failed to provide stair enclosures that comply with NFPA 101 (Life Safety Code) for 1 of 3 stair enclosures. The smokeproof enclosure that extends from the end to the West stairway to the outside is not properly protected. This deficiency could affect all 98 patients in the facility.

NFPA 101:19.2.2 Means of Egress Components
19.2.2.4 Smokeproof enclosures complying with 7.2.3 shall be permitted.

7.2.3.3 A smokeproof enclosure shall be enclosed from the highest point to the lowest point by barriers having 2-hour fire resistance ratings. Where a vestibule is used, it shall be within the 2-hour-rated enclosure and shall be considered part of the smokeproof enclosure.

Findings:

During a tour of the facility conducted from February 3 through February 4, 2010, observation revealed that smokeproof enclosure at the bottom of the West stairway is not properly protected. This enclosure has pipes, conduit, and ducts that do not serve this area and/or serves this enclosure and as well as other areas. Any equipment not used for the stairway enclosure only shall be separated from the stairway by a 2-hour fire-resistive rating.

Based on observation the facility failed to provide corridors that are clear and unobstructed for the complete width of the corridor for 7 of 19 halls on 3 of 6 floors in the facility. This deficiency affects all 98 patients in the facility.

Note: NFPA 101, 2000 edition
NFPA 101:7.1.10 Means of Egress Reliability.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress there from, or visibility thereof.

Findings:

During a tour of the facility conducted from February 3 through February 4, 2010, chairs were observed blocking the exit access of the stairwells in the following areas. This area of the corridor is required to be clear and unobstructed to allow personal to remove patients down the stairwell in the event of an emergency.

1. 4th floor North hall had three chairs at the end of it.
2. 4th floor South hall had a couch at the end of it.
3. 4th floor West hall had three chairs at the end of it.
4. 5th floor South hall had two chairs at the end of it.
5. 5th floor West hall had a chair at the end of it.
6. 6th floor North hall had two chairs at the end of it.
7. 6th floor West hall had three chairs at the end of it.