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Based on observation, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Section 7.2.1.5.1.

Findings include:

1. During an observation on 8/21/23 at 3:12 p.m., the 200 hall exit pathway to the public way led through a gate, the gate was found to have the latch on the entry side of the gate. There was no opening hardware on the egress side of the gate. Door leaves shall be arranged to be opened readily from the egress side whenever the building is occupied.

Based on observation, the facility failed to ensure latching fire/smoke barrier doors were maintained per NFPA 101-2012, Section 19.3.7.8. and 4.2.3, and 4.6.12.

Findings Include:

1. During an observation on 8/21/2023 at 2:25 p.m., the 2-hour doors leading to the 500 (administration) wing were exercised. The doors failed to close and latch under the power of the self-closers.

2. During an observation on 8/21/23 at 3:28 p.m., the 2-hour doors leading to the ancillary hall were exercised. The doors failed to close and latch under the power of the self-closers.

3. During an observation on 8/21/23 at 3:28 p.m., the 2-hour doors leading to the clinic were exercised. The doors failed to close and latch under the power of the self-closers.

Based on observation, the facility failed to ensure hazardous rooms/areas had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 8/21/23 at 2:29 p.m., the clean side of the laundry door was found to have had the self-closing device detached from the closing mechanism, the door would not close and latch under the power of the self-closer.

2. During an observation on 8/21/23 at 2:35 p.m., the U-shoppe storage room was inspected. The room contained a lot of combustible items in storage. The room was over 50 square feet and lacked the required self-closer on the door.

3. During an observation on 8/21//23 at 2:49 p.m., resident room 321 was used as a storage room. The room was over 50 square feet and lacked the required self-closer on the door.

Based on record review, the facility failed to maintain the kitchen hood extinguishing system in accordance with NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition, Section 11.2.1.

Findings include:

1. Record review of the kitchen hood system records for the suppression system reflected a lack of documentation to show the contractor had performed services on a semi-annual basis. The last recorded inspection of the hood extinguishing system was November of 2022. The hood system was due to be inspected again in May of 2023.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).

Findings include:

1. During an observation on 8/21/23 at 3:36 p.m., the ancillary hall was inspected. There was an ABHR dispenser mounted over a light switch in the hall.

Based on observation, the facility failed to:

a) maintain the monthly gauge readings on all of the sprinkler risers per NFPA 25-2011, Sections 5.2.4.1 and 5.2.4.2;
b) continuously maintain automatic fire sprinklers in reliable operating condition including examination of the heads per NFPA 25-2011, Sections 5.2.1.1.2.;
c)ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.;
d) failed to ensure the inspector's test orifice was installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.17.4.2.1.
e) ensure pendant type sprinkler heads were mounted at proper distances under unobstructed construction per NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.4.1.1.1.

Findings include:

1. Review of inspection reports for the facility's wet sprinkler system on 08/21/2023, showed the facility lacked documentation of the monthly pressure gauge readings for the facility's wet sprinkler system.

2. During an observation on 8/21/23 at 2:30 p.m., the sprinkler head behind the dryers was inspected. It was discovered to be choked with lint and debris.

3. During an observation on 8/21/23 at 3:00 p.m., the boiler room was inspected. The sprinkler pipe in the room was found to have heat tape and insulation wrapped around a section of the pipe. There was also a nylon rope suspending another section of pipe covered by the insulation.

4. During an observation on 8/21/23 at 3:19 p.m., the inspector's test pipe was inspected. The pipe was a 1" pipe with matching valve and was drained into the drain where the washing machines are. The orifice was larger than the smallest orifice on the system.

5. During an observation on 8/21/23 at 3:32 p.m., the furnace room was inspected. There was a gas line suspended from a section of the sprinkler pipe in the room.

6. During an observation on 8/21/23 at 3:38 p.m., the area by the dining room double doors was inspected. There was a sprinkler head which was found to have the defector only 1/4" below the ceiling. The deflector must be a minimum of 1" below the ceiling.

Based on observation, the facility failed to ensure timely (every 5 years) hydrostatic testing for the K type extinguisher, located in the kitchen, in accordance with NFPA 101-2012, Section 9.7.4.1 and NFPA 10-2010, Section/Table 8.3.1 Hydrostatic Test Intervals for Extinguishers.

Findings include:

1. During an observation on 8/21/23 at 2:38 p.m., the portable K tank in the kitchen was inspected. The tank had not had a hydrotest completed within the 5 year limit. The tank was last hydrotested in 2017.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6 and 19.7.2.2.

Findings include:

1. During a review of facility fire drills on 8/21/2023, it was determined the facility had not completed a fire drill for the night shift of the third quarter of 2022. Fire drills must be completed during the established shift hours.

Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report).

Findings include:

1. Review of the fire safety maintenance records on 8/21/2023, reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangement in the building and show inspections of all components of the doors in those barriers.

Based on observation, the facility failed to ensure a labeled remote manual stop station for the generator was installed in accordance with NFPA 110-2010, Section 5.6.5.6 and 5.6.5.6.1.

This deficiency affects the entire facility.

Findings include:

1. During an observation on 8/21/23 at 3:22 p.m., the generator was inspected. The generator lacked a labeled manual stop station at a remote location on the outside of the room housing the generator, of a type in order to prevent inadvertent or unintentional operation of the generator in an emergency.

Based on observation, the facility failed to keep the room housing the Emergency Power Supply System (EPSS) free from any other equipment per NFPA 110 2010 Edition, Section 7.2.1.2.

This deficiency affects 1 of 5 smoke compartments.

Findings include:

1. During an observation on 8/21/23 at 3:22 p.m., the generator room was inspected. The room housing the generator was also being used as a storage room for items such as a refrigerator, microwave, and a small cabinet. The room housing the generator can only be used to store items for maintaining the generator.

Based on observation, the facility failed to store oxygen cylinders in accordance with NFPA 99, 2012 Edition, Section 11.3.4.2 and 11.3.2.1.

Findings include:

1. During an observation on 8/21/23 at 2:56 p.m., a marked storage room was inspected. There were E-sized oxygen tanks being stored in the room. There were two doors to the room. There was no proper signage for oxygen storage on the doors. The back entry door through a hall way was not lockable.