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Based on observation and facility staff interview, the facility failed to provide 1-hour rated separation between hazardous areas (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances) and other areas in the facility. Failure to provide one hour rated walls and provide a fire rated door equipped with a self-closing device puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area. The facility census was 2.


Observation on 1/12/2016 at 3:15 PM, during the facility tour, showed patient room #103 was converted to storage use. The room contained a large quantity of combustible materials stored on portable shelving units and on the floor of the room. Observation showed the room measured approximately 240 square feet. The room entrance door did not have a 3/4 hour rating and was not equipped with a self closing device.

During an interview on 1/12/16 at 3:18 AM, Staff H, Plant Operations, stated the facility uses patient room #103 for storage because they do not have enough storage space.

NFPA 101, 2000 edition, section 18.3.2.1 states: "Hazardous Areas. Any hazardous area shall be protected in accordance with section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated."

NFPA 101, 2000 edition, Table 18.3.2.1 states:

"Hazardous Area Description Separation/Protection

Storage rooms larger than 100 square ft 1 hour" (9.3 m squared) storing combustible material