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Based on observation and interview with the Fire Inspector, 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 Included:

During the Fire & Life Safety tour of the facility with the Fire Inspector on 3/12/2019 from 8am to 4pm, it was observed that the 1 hour rated Fire/Smoke door for Room #2173 was not closing properly, and needed a closure. The room was used for record storage.

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 and interview with the Fire Inspector, 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 included:

During the Fire & Life Safety tour of the facility with the Fire Inspector, from 03/11/19 through 3/14/19 from 8am to 4 pm, it was found that Room #1147 had a penetration around the air conditioning duct that had not been fire stopped or smoke sealed.

The Fire Inspector verified the finding at the time observed.

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

Based on record review and interview with the Fire Inspector, the facility failed to maintain fire doors, which are required to have a fire protection rating by Table 8.3.4.2 and shall be protected by approved, listed, labeled fire door assemblies, fire window assemblies, and their accompanying hardware, including frames, closing devices, anchorage, and sills in accordance with NFPA 80 standard for fire doors. Failure to maintain dividing fire barriers may result in fire spreading to other compartments and endangering building occupants.

The findings included:

During record review with the Fire Inspector on 3/12/2019 at 7:30 a.m., evidence of the annual fire door inspections could not be produced.

An interview conducted with the Fire Inspector concurrent with the record review confirmed the finding.

Fire doors assemblies are inspected and tested annually in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protectives. Fire doors that are not located in required fire barriers, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspection and testing have an understanding of the operating components of the doors. Written records of inspection and testing are maintained and are available for review.
Per NFPA 101 (2012 Edition) 19.7.6, 8.3.3.1
NFPA 1 (2012 Edition) 12.4.6.6
Per NFPA 80 (2010 Edition) 5.2, 5.2.3

Based on observation and interview with the Fire Inspector, the facility failed to maintain electrical equipment and wiring in accordance with NFPA 70 the National Electric Code (N.E.C.), and NFPA 99 Health Care Facilities Code and to provide a facility free from electrical hazards. Failure to maintain electrical devices, equipment, and wiring in accordance with the applicable standards can result in the hazards of electric shock, electrocution, energized equipment and fire resulting from electric sources.

Findings included:

During the Fire & Life Safety tour of the facility with the Fire Inspector, from 03/11/19 through 3/14/19 from 8am to 4pm, it was found that there was relocatable power taps (RPT's), and extension cords in use in:
1. Room # 1118, patient bed not tested
2. Room # 1124, patient bed not tested
3. Room # 1114, conduit pulled away from wall

The Fire Inspector verified these findings at the times observed.

Multiple outlet connections shall comply with NFPA 99 (2012 edition) 10.2.3.6. An in accordance with their listing.