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Based on observations and interview with the Maintenance Director, the facility failed to maintain the exit doors free of obstructions. Exit doors obstructed can delay or restrict needed egress from the building in an emergency situation and endangering building occupants.

Findings included:

During the facility tour with the Maintenance Director on 11/05/2019 between 1:15p.m. and 4:15p.m., it was revealed that the path of egress to the secondary exit in the maintenance shop was obstructed by various pieces of equipment. An interview was conducted with the Maintenance Director concurrent with the observations and confirmed the findings. (Photographic Evidence Obtained)

per NFPA 101 (2012 Edition) 19.2.1, 7.1.10.1, 7.1.10.2.1

Based on observations and interview with the Maintenance Director, the facility failed to prohibit storage in the exit stairwell.

Findings included:

During the facility tour with the Maintenance Director on 11/05/2019 between 1:15p.m. and 4:15p.m., it was found that Stairwell A had storage of chairs on the ground floor (Photographic Evidence Obtained). An interview was conducted with the maintenance director concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 19.2.2.3, 7.1.3.2.2, 7.1.3.2.3, 7.1.10.1, 7.2.2.5.3, 7.2.2.5.3.1

Based on observations and interview with the Maintenance Director, the facility failed to maintain the commercial cooking hood located in the dietary kitchen. Failure to maintain the commercial cooking equipment safety devices could endangering building occupants if equipment is not properly maintained.

Findings included:

During the facility tour with the Maintenance Director on 11/05/2019 between 1:15p.m. and 4:15p.m., it was observed that the commercial cooking hood internal hood joints, seams, and filter supports were not sealed or otherwise made greasetight (Photographic Evidence Obtained). An interview was conducted with the Maintenance Director concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 19.3.2.5, 9.2.3
per NFPA 96 (2011 Edition) 5.1.4

Based on observations and interview with the Maintenance Director, the facility failed to install alcohol based hand rub (ABHR) dispensers per NFPA 101 requirements.

Findings included:

During the facility tour with the Maintenance Director on 11/05/2019 between 1:15p.m. and 4:15p.m., it was observed that ABHR dispensers were installed within one inch of ignition sources in the dry food storage room and the B Unit nurses' station. An interview was conducted with the Maintenance Director concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 19.3.2.6(8)

Based on observations and interview with the maintenance director, the facility failed to maintain the automatic fire sprinkler system (AFSS). Failure to maintain the AFSS could result in a delayed or premature response of the sprinkler system. This could affect building occupants in a fire emergency.

Findings included:

During the facility tour with the Maintenance Director on 11/05/2019 between 1:15p.m. and 4:15p.m., and on 11/06/2019 between 9:30a.m. and 9:55a.m., it was revealed that:

1) 11 of the 14 sprinklers located in the loading dock were loaded
2) The sprinkler located in the C Unit medication room was loaded
3) 1 of the 5 sprinklers located in the administration corridor by room E125 were loaded

An interview was conducted with the maintenance director concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 19.3.5, 9.7
per NFPA 25 (2011 Edition) 5.2.1.1.1, 5.2.1.1.2

Based on observation and interview with the Maintenance Director, the facility failed to properly maintain the required fire/smoke barrier penetration(s), which have not been fire stopped or smoke sealed per the requirements of NFPA 101.

Findings included:

During the facility tour with the Maintenance Director on 11/05/2019 between 1:15p.m. and 4:15p.m., it was observed that the facility failed to properly maintain the required Fire/Smoke barrier penetrations in the following areas:

1) The wall above the corridor doors by room H106 had penetrations around conduit that were not sealed
2) The wall above the corridor doors by room G110 had penetrations around the conduit that were not sealed

An interview was conducted with the maintenance director concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 19.1.1.3, 19.3.7.1, 8.3.5

Based on observation and interview with the Maintenance Director, the facility failed to maintain proper storage of flammable liquids or gases. Proper storage and handling of flammable liquids or gases are vital to the safety of staff, patients, and visitors within the facility.

Findings included:

During the facility tour with the Maintenance Director on 11/05/2019 between 1:15p.m. and 4:15p.m., a filled liquid petroleum (LP) propane tank was found freestanding in the path of egress of the secondary exit located in the maintenance shop (photographic evidence obtained). An interview was conducted with the Maintenance Director concurrent with the observations and confirmed the findings.
per NFPA 101 (2012 Edition) 8.7.3.1, 8.7.3.2
per NFPA 58 (2011 Edition) 8.2.1.1, 8.2.1.3

Based on observations and interview with the Maintenance Director, the facility failed to maintain required equipment in the patient and employee smoking areas.

Findings included:

During the facility tour with the Maintenance Director on 11/05/2019 between 1:15p.m. and 4:15p.m., it was revealed that the facility failed to provide the following in all areas where smoking was permitted. This included the A, B, and C unit patient smoking areas, the outpatient smoking area, and the employee smoking area:

1) Metal containers with self-closing cover devices into which ashtrays can be emptied.
2) Ashtrays of noncombustible material and safe design.

An interview was conducted with the Maintenance Director concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 19.7.4(5)(6)

Based on record review and interview with the Maintenance Director, the facility failed to provide evidence of generator maintenance and testing in accordance with NFPA 110 (2010 Edition). Failure to maintain the prime mover will result in a loss of power to the facility thus endangering the residents and occupants of the facility.

Findings included:

During record review with the Maintenance Director on 11/05/2019 between 9:45a.m. and 12:15p.m., the facility failed to provide evidence of the monthly conductance testing of the generator's maintenance free battery. An interview was conducted with the Maintenance Director concurrent with the observations and confirmed the findings.

per NFPA 99 (2012 Edition) 6.4.1.1.13, 6.4.4.1.1.14, 6.5.4.1.1.2
per NFPA 110 (2010 Edition) 8.3.7.1

Based on observation and interview with the Maintenance Director, the facility failed to prevent the use of multi-outlet adapters and daisy-chained power strips. Electrical fires can start when circuits are overloaded in the walls or attic where it can go undetected, giving the hazard time to spread, placing the facility at risk.

Findings included:

During the facility tour with the Maintenance Director on 11/05/2019 between 1:15p.m. and 4:15p.m., and on 11/06/2019 between 9:30a.m. and 9:55a.m., it was revealed the facility failed to prevent the use of multi-outlet adapters and daisy-chained power strips in the following areas:

1) The T.M.S. room G137
2) Recreational office room G112
3) Administration office E125

An interview was conducted with the Maintenance Director concurrent with the observations and confirmed the findings.

per NFPA 1 (2012 Edition) 11.1.5.2, 11.1.6.2