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The inspector observed, while accompanied by the Administrator during the hours of the inspection from 2:30 pm to 5:30 pm on 5/7/2019 that there were the following issues. The following documents were not available for inspection during this inspection.

Fire-rated door assemblies and certain other doors in the means of egress shall be tested annually or per an accepted performance-based evaluation schedule approved by the AHJ per NFPA 80, 2010, Ch. 5.2. A written record of the inspections and testing shall be signed and kept for inspection by the AHJ. NFPA101, 7.2.1.15

The inspector observed, while accompanied by the Administrator during the hours of the inspection from 2:30 pm to 5:30 pm on 5/7/2019 that there were the following issues. A fire alarm pull box was missing from the front door location. Fire alarm pull boxes are required within five feet of each exit per the following requirements.

"Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any detection devices or detection systems required." - NFPA 101, 2003, 20.3.4.2. (see next)

A manual fire alarm box shall be provided in the natural exit access path near each required exit from an area, unless modified by another section of this Code. NFPA 101, 2003, 9.6.2.3.

"Manual fire alarm boxes shall be located within 1.5m (5 feet) of exit doorway opening at each exit on each floor." NFPA 72, 2004, 5.12.6

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Life safety electrical panel. The fire alarm circuit was missing the correct signage per the following requirements.

"The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL"" - NFPA 72, 2010: 10.5.5.2.2

"The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit." - NFPA 72, 2010: 10.5.5.2.1

The inspector observed, while accompanied by the Administrator during the hours of the inspection from 2:30 pm to 5:30 pm on 5/7/2019 that there were the following issues. The double doors located near Administration need an astragal or equivalent per the following requirements.

Smoke barrier doors shall be a minimum of 1 3/4" thick, solid-bonded wood core or equivalent with self-closing or automatic-closing devices in accordance with 21.2.2.4. Latching hardware is not required. Doors are required to swing in the direction of egress travel. Rabbets, bevels, or astragals are at meeting edges, and stops are at the head and sides of door frames. Center mullions are prohibited in smoke barrier door openings 20.3.7.9, 20.3.7.10, 20.3.7.13, 20.3.7.14

The inspector observed, while accompanied by the Administrator during the hours of the inspection from 2:30 pm to 5:30 pm on 5/7/2019 that there were the following issues. The following documents were not available for inspection during this inspection.

Risk Assessment: Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel, see Chapter 4 (NFPA 99). The facility must define its risk assessment methodology, implement the methodology, and document the results in relation to the risk categories contained in the NFPA99 Health Care Facilities Code. No particular risk assessment procedure is required. The facility will determine the procedure that most meets their needs within the requirement of the NFPA code. For additional information see the appendix of NFPA 99, A4.1 and A4.2.

The inspector observed, while accompanied by the Administrator during the hours of the inspection from 2:30 pm to 5:30 pm on 5/7/2019 that there were the following issues. An electrical room was being used for storage.

No Storage Allowed Electrical Room: "Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage." - NFPA 70, 2012, 110.26(E)

The inspector observed, while accompanied by the Administrator during the hours of the inspection from 2:30 pm to 5:30 pm on 5/7/2019 that there were the following issues. Documents were not available for inspection for the receptacle logs per the following requirements.
Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99)

The inspector observed, while accompanied by the Administrator during the hours of the inspection from 2:30 pm to 5:30 pm on 5/7/2019 that there were the following issues. Pharmacy: The refrigerated drug storage was plugged into a white receptacle. It must be plugged into the emergency electrical system. (red receptacle)