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Based on observation and staff interview, the facility failed to ensure that the corridor doors fit tightly within the doorframe to resist the passage of smoke. This deficient practice affects occupants in three of six smoke zones, as the doors would not prevent the spread of fire and smoke. This facility had a census of 46 patients..
Findings are:

Observations on 7/23/13 between 1:42 pm and 3:30 pmrevealed:
1. The double doors to Madison room contained a greater that 1/8th inch opening between the two leafs.

2. The corridor door to Rooms 220 and 231 failed to close and latch when tested.

3. The corridor door to Room 204 failed to be smoke resisting as the top of the door was below the door stop.

All observations were confirmed by Maintenance Staff A at the times of the observations.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors shall be provided with positive latching hardware. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and interview, the facility failed to maintain doors in smoke barriers to be smoke resisting. The smoke doors affected two of the six smoke compartments in the building. The smoke doors not closing flush would allow smoke and heated gases to enter the smoke zones and inhibit evacuation from the zones.
Findings are:

1. Observation on 7/23/13 at 2:10 pm revealed the failure of the smoke barrier door leafs 2330A, by Room 2333 to close flush when tested.

Maintenance Staff A confirmed the leafs failure to close flush at the time of the observation.
NFPA Standard: Requires doors in smoke barriers to be self-closing and have at least a 20-minute rating, 2000 NFPA 101, 19.3.7.6

Based on observation and interview the facility failed to maintain three feet in front of all electrical panelboards and to not use electrical panelboard rooms for storage. This deficient practice affected two of six smoke zones. The facility census was 46.
Findings are:

1. Observation on 7/23/13 at 2:00 pm revealed the Electrical panel room 2319 contained construction storage within 3 feet in front of the electrical panels.

2. Observation on 7/23/13 at 3:00 pm revealed the Electrical panel room 2272 contained construction storage within 3 feet in front of the electrical panels.

Interview with Maintenance Staff A at each of the observations revealed the construction storage was for the remodel of the shower rooms.


NFPA Standard: Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
Minimum Clear Distance (ft)
Nominal Voltage to Ground Condition 1 Condition 2 Condition 3
0-150 3 3 3
151-600 3 31/2 4

(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
(3) Height of Working Space. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26(e). Within the height requirements of this section, other equipment associated with the electrical installation located above or below the electrical equipment shall be permitted to extend not more than 6 in. (153 mm) beyond the front of the electrical equipment.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.
(c) Access and Entrance to Working Space. At least one entrance of sufficient area shall be provided to give access to the working space about electric equipment.
For equipment rated 1200 amperes or more and over 6 ft (1.83 m) wide that contains overcurrent devices, switching devices, or control devices, there shall be one entrance not less than 24 in. (610 mm) wide and 6? ft (1.98 m) high at each end of the working space.
Exception No. 1: Where the location permits a continuous and unobstructed way of exit travel, one means of access shall be permitted.
Exception No. 2: Where the work space required by Section 110-26(a) is doubled, only one entrance to the working space is required. It shall be located so the edge of the entrance nearest the equipment is the minimum clear distance given in Table 110-26(a) away from such equipment.
(d) Illumination. Illumination shall be provided for all working spaces about service equipment, switchboards, panelboards, or motor control centers installed indoors. Additional lighting fixtures shall not be required where the work space is illuminated by an adjacent light source. In electrical equipment rooms, the illumination shall not be controlled by automatic means only.
(e) Headroom. The minimum headroom of working spaces about service equipment, switchboards, panelboards, or motor control centers shall be 6? ft (1.98 m). Where the electrical equipment exceeds 6? ft (1.98 m) in height, the minimum headroom shall not be less than the height of the equipment.
Exception: Service equipment or panelboards, in existing dwelling units, that do not exceed 200 amperes.
(f) Dedicated Equipment Space. Equipment within the scope of Article 384, and motor control centers, shall be located in dedicated spaces and protected from damage as covered in (1) and (2).
Exception: Control equipment that by its very nature or because of other rules of the Code must be adjacent to or within sight of its operating machinery shall be permitted in those locations.
(1) Indoor. For indoor installations, the dedicated space shall comply with the following.
a. Dedicated Electrical Space. The space equal to the width and depth of the equipment and extending from the floor to a height of 6 ft (1.83 m) above the equipment or to the structural ceiling, whichever is lower, shall be dedicated to the electrical installation. No piping, ducts, or equipment foreign to the electrical installation shall be located in this zone.
Exception: Equipment that is isolated from the foreign equipment by height or physical enclosures or covers that will afford adequate mechanical protection from vehicular traffic or accidental contact by unauthorized personnel or that complies with b., shall be permitted in areas that do not have the dedicated space described in this rule.
b. Foreign Systems. The space equal to the width and depth of the equipment shall be kept clear of foreign systems unless protection is provided to avoid damage from condensation, leaks, or breaks in such foreign systems. This zone shall extend from the top of the electrical equipment to the structural ceiling.
c. Sprinkler Protection. Sprinkler protection shall be permitted for the dedicated space where the piping complies with this section.
d. Suspended Ceilings. A dropped, suspended, or similar ceiling that does not add strength to the building structure shall not be considered a structural ceiling.
(2) Outdoor. Outdoor electrical equipment shall be installed in suitable enclosures and shall be protected from accidental contact by unauthorized personnel, or by vehicular traffic, or by accidental spillage or leakage from piping systems. The working clearance space shall include the zone described in Section 110-26(a). No architectural appurtenance or other equipment shall be located in this zone. 1999 NFPA 70, 110-26, Table 110-26(a).