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Based on observation and interview with the Fire Inspector, the facility failed to provide inspection, maintenance and testing of the fire sprinkler system in accordance with NFPA 25. Failure to inspect, maintain, and test system components could result in the system failing to perform as designed.

Findings included:

During the Fire & Life Safety tour of the facility with the Fire Inspector on 03/12/2019 from 8am to 4pm, sprinkler heads were observed in the following areas to be in need of replacement:
1. Room # 421, dirty sprinkler heads
2. Room # 317, concealed sprinkler head cover has been sealed to the ceiling
3. Room # 217, concealed sprinkler head cover has been sealed to the ceiling by paint
4. Rear wheel chair ramp is not sprinkled
5. Covered area to the green house is not sprinkled
6. Sprinkler gauges in the attic dated 2012, over 5 years

The Fire Inspector was present during the observation and confirmed the findings.

According to NFPA 25 (2011 edition) 5.2.1.1.1; "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage. And shall be installed in the correct orientation." and 5.2.1.1.2; "Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5) Loading, (6) Painting unless painted by the sprinkler manufacturer."

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 several 1 hour rated Fire/Smoke doors were not closing properly:
1. Resident room # 415, gap at top of door which could allow fire, smoke and fire gasses to enter the compartment.
2. Room # 144, door needed a closure because of the amount of storage in the room being a hazard.
3. Room # 131, door needed a closure, storage of records in the room.
4. Room # 101, gap at top of door which could allow fire, smoke and fire gasses to enter the compartment.

The Fire Inspector 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 record review and interview with the Fire Inspector, the facility failed to maintain 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 findings.

Opening required to have a fire protection rating by Table 8.3.4.2 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.
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 prohibit unapproved portable space heaters. Radiant heaters are a source of ignition and thereby are a danger to staff and occupants of the building

The Findings Included:

During the Fire & Life Safety tour of the facility with the Fire Inspector from 03/11/19 through 3/14/19 between 8am to 4pm, it was observed that the facility failed to prohibit unapproved portable space heaters. Heaters were found in the following locations:
1. Room # 256, unapproved portable space heater
2. Room # 150, unapproved portable space heater
3. Room # 430, unapproved portable space heater

The Fire Inspector verified these findings at the times observed.

Portable space-heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met: (1) such devices are used only in non-sleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (100°C).
NFPA 101 (2012) 18.7.8 & 19.7.8.