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Based upon record review and staff interviews on 01/23/2018 between approximately 0845 and 1030 hours and during the physical tour of the facility between 1030 and 1400 hours, the facility has failed to conduct testing/maintenance of fire rated doors as required by NFPA 80. The facility has also failed to maintain exit corridors free of all obstructions. This could cause an inability or delay in the evacuation of residents in the event of an emergency and could result in the failure of the fire rated door to operate properly which would endanger the patients, staff and/or visitors within the facility.

The findings include, but are not limited to:


- The facility was unable to provide documentation of the annual inspection and testing of labeled fire doors per NFPA 80 - 5.2.4.1

-The facility had dining room tables and chairs set up in a corridor alcove near resident room #6. Residents were observed eating a meal at the table and obstructing the clear width of the exit corridor with their chair and nearby walker.




The above was discussed and acknowledged by the Facility Maintenance Director who said he was aware of the periodic requirement and testing of labeled fire doors, but had not completed them yet. The Facility Maintenance Director was also unaware of the dining table and chairs could not be in the corridor / dead-end alcove.

Based upon observations and staff interviews on 01/23/2018 during the physical tour of the facility between approximately 1030 and 1400 hours the facility has failed to maintain the ability of doors to close and be kept closed upon release of their automatic door closers. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:

- The door that opens to the corridor from the Laboratory did not have enough self closer force to fully close and latch.

- The cross corridor fire doors near the Reception desk has an in-operable door closing coordinator that is preventing the doors from fully closing and latching.


The above was discussed and acknowledged by the Facility Maintenance director who said they had not previously observed the doors to not close and latch.

Based upon observations and staff interviews along with record review on 01/23/2018 during the inspection of the facility between 1030 and 1400 hours the facility has failed to maintain the laboratory fire protection plan in accordance with
NFPA 45. This could result in a failure to for staff to respond appropriately in the event of a lab fire, resulting in potential harm to staff, patients and visitors.


The findings include, but are not limited to:

-The Lab does not have procedures for extinguishing a clothing fire in their lab-specific emergency plan as required by NFPA 45-6.6.3.2.

The above was discussed and acknowledged by the Maintenance Director who said that they were unaware the requirements.

Based upon document review and staff interviews on 01/23/2018 between approximately 0845 and 1030 hours the facility has failed to maintain the fire alarm system as required by NFPA 72. This could result in the failure of the fire alarm system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:


-According to documentation provided by the facility, their Automatic and Manual fire alarm system has 9 out of 41 smoke detectors that have failed the smoke detector sensitivity test conducted on 10/14/2017.


The above was discussed and acknowledged by the Maintenance Director who said he was unaware that the fire alarm system had failed the smoke detector sensitivity test.

Based upon observation and staff interviews on 01/23/2018 during the physical tour of the facility between approximately 1030 and 1400 hours the facility has failed to maintain the fire sprinkler system as required by NFPA 25. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

-There is a broken sprinkler pipe hanger in the Central Supply Room.

-There are wires hanging from the sprinkler piping in the Materials Purchasing Room. Per 2011 NFPA 25-5.2.2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

-There are combustible materials within 18 inches of the sprinklers in the atrium storage room.


The above was discussed with the Facility Maintenance Director who stated he had not previously observed the broken sprinkler pipe hanger or the wires on the sprinkler pipe or the combustible materials stored improperly.

Based upon observations and staff interviews on 01/23/2018 during the physical tour of the facility between approximately 1030 and 1400 hours, the facility has failed to properly maintain the Type 2 EES in the facility. This could result in electrical malfunction which could potentially endanger residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

-The CR-Critical Branch Panel located on the 1st floor near the Emergency Room ambulance entrance contains the Staff Break Room found on circuit 23, which is not authorized per NFPA 99-6.4.2.2.4.2.



The above was discussed and acknowledged by the Facility Maintenance Director who said they were unaware that the staff break room circuit was not allowed on the critical branch panel.

Based upon record review and staff interviews on 01/23/2018 between 0845 and 1030 hours the facility has failed to test the emergency generator fuel in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff and/or visitors within the facility.

The findings include, but are not limited to:

-The facility was unable to provide documentation showing that a fuel quality test has been performed per NFPA 110-8.3.8 within the past 12 months.

The above was discussed and acknowledged by the Maintenance Director who stated the he believed the fuel had been tested within the past 12 months, but was unable to provide the documentation.