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Based on observation made during the Fire & Life Safety tour and confirmation by the Director of Maintenance, the facility failed to maintain proper maintenance of the Fire/Smoke doors. This condition could result in (2) smoke compartments to become involved in a fire/smoke situation. This could allow fire, smoke and fire gasses to enter the compartment, which would impede or deny the exiting of occupants in an emergency and result in harm to the occupants from the dangers of the emergency.

The Findings Include:

During the Fire & Life Safety tour of the facility with the Director of Maintenance on 08/14/2018 from 9am to 2:30pm, it was observed that several 1 hour rated Fire/Smoke doors were not closing properly.
1. Resident room door # 163, not latching
2. ICU, resident room, # 2 door not closing
3. ICU, resident room, # 3 door not closing
4. Resident room # 123, door not latching
5. Resident room # 128, door not latching
6. Resident room # 125, door propped open with a trash receptacle

The Director of Maintenance was present during the observations, and confirmed the findings.

NFPA 101, (2012 edition,) Chapter 19, 19.3.6.3.5, "Doors shall be provided with a means for keeping the door closed that is acceptable to the AHJ."

Based on observation made during the Fire & Life Safety tour and confirmation by the Director of Maintenance, the facility failed to properly maintain the required fire/smoke barrier penetrations, which had not been fire stopped or smoke sealed per the requirements of NFPA 101(2012 edition). This condition could allow fire/smoke to travel from one compartment to other compartments, thus endangering occupants of the facility.

Findings include:

During the Fire & Life Safety tour of the facility with the Director of Maintenance on 08/14/2018 from 9am to 2:30pm, it was found that penetrations through the wall above the ceiling had not been fire stopped or smoke sealed. The following locations were observed to have penetrations:
1. Penetration above the ceiling next to room # 1162
2. Penetration above the self-closing double doors next to room # 1204
3. Penetration above the Fire doors next to room # 1161
4. Penetration above the ceiling next to room # 124
5. Penetration above the self-closing double doors next to room # 1104
6. Penetration above the self-closing double doors going into ICU
7. Penetration in wall in electrical room # 1107, several conduit pipes
8. Unapproved spray foam used in a pipe in the floor in room # 1218
All locations were not properly protected with the required fire caulk.

Maintenance was shown the penetrations and confirmed the findings.

According to NFPA 101(2012 edition) 8.4.4 & 8.4.4.1 and 19.3.7.6

Based on the Fire & Life Safety document review and confirmation by the Director of Maintenance, the facility failed to provide maintenance, inspection & testing of fire doors. This condition could allow fire/smoke to travel from one compartment to other compartments, thus endangering occupants of the facility.

Findings include:

During the Fire & Life Safety document review with the Director of Maintenance on 08/14/2018, it was observed that the facility failed to maintain records of fire door maintenance, inspection & testing by a qualified person. These findings were confirmed by the Director of Maintenance.

Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review.

19.7.6, 8.3.3.1 (LSC), NFPA 80 (2010 edition) 5.2, 5.2.3

Based on observation made during the Fire & Life Safety tour and confirmation by the Director of Maintenance, the facility failed to properly store compressed medical gas cylinders (oxygen) in accordance with NFPA 99, Health Care Facilities Code. Improper storage of medical gas cylinders could result in the rupture of the cylinders and subsequent accelerated development of fire, smoke and fire gasses in a fire situation.

Findings include:

During the Fire & Life Safety tour of the facility with the Director of Maintenance on 08/14/2018, it was observed that room # 1040 was identified as containing oxidizing and compressed gasses. Approximately 19 E-size cylinders were located in the room both in the empty bin and in full bin. Also located in the room, within 5ft., were several containers of the aerosol hand cleaner with a warning label stating: "highly flammable," along with other combustible items. The total volume of the compressed gasses exceeded 300 cubic feet.

The Director of Maintenance was present during the observation, and confirmed the findings.

According to NFPA 99 (2012 edition) 11.3.2.1. "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited combustible construction. With doors (or gates outdoors) that can be secured against unauthorized entry.", and 11.3.2.3; "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft.) (2) Minimum distance of 1.5 m (5 ft.) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13. Standard for the Installation of Sprinkler Systems. (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1?2 hour." and 11.3.4.1. "A precautionary sign, readable from a distance of 1.5 m (5 ft.), shall be displayed on each door or gate of the storage room or enclosure.", and 11.3.4.2; "The sign shall include the following wording as a minimum: 'CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING'."