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Based on observation during the Life Safety Survey and interviews with the maintenance director, the facility failed to maintain proper maintenance of the Fire/Smoke doors. This condition could result in (2) Smoke Compartments becoming 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 situation.

The findings Include:

During the facility tour with the Maintenance Director on 02/09/2016 at 10:30 am, the following was observed:

1. Two sets of Fire/Smoke doors in hall D1 were not closing properly.
2. The door connecting the kitchen and dining room was not latching.
3. The door connecting the dayroom and hall D1 was not latching.
4. The dry storage door was being propped open with can goods.
5. The front door in the business office was being held open by a door stop.

The maintenance Director advised he would make repairs on doors as needed and remove all unapproved door stops.

NFPA 101, (2000 edition,) Chapter 19, 19.3.6.3.5 states, "Doors shall be provided with a means for keeping the door closed that is acceptable to the AHJ."

Based on observation during the Life Safety Survey and interviews with the maintenance director, the facility failed to properly maintain the required Fire/Smoke barrier penetrations, which have not been fire stopped or smoke sealed per the requirements of NFPA 101(2000 edition). This condition could allow Fire/Smoke to travel from one compartment to other compartments, thus endangering occupants of the facility.

Findings include:

During the facility tour with the Maintenance Director on 02/09/2016 at 12:15 pm, the following was observed:

1. Penetrations through the wall above the ceiling have not been fire stopped or smoke sealed in the nurses station.
2. Penetrations through the wall above the ceiling have not been fire stopped or smoke sealed in the kitchen storage closet.
3. Penetrations through the wall above the ceiling have not been fire stopped or smoke sealed in the mechanical room.

The maintenance Director was shown the penetrations and confirmed the findings.

According to NFPA 101(2000 edition) 8.3 and 19.3.7

Based on observation during the Life Safety Survey and interviews with the maintenance director, the automatic sprinkler system was not installed in accordance with NFPA 13. During the event of fire, this could delay or deny extinguishment of a fire.

Findings include:

During the facility tour with the Maintenance Director on 02/09/2016 at 1:05 pm, the following was observed:
1. The sprinkler head in the small laundry room was blocked by a light fixture.
2. The sprinkler head in the seclusion room was blocked by a light fixture.
3. The therapy office, (2) sprinkler heads were observed spaced less than 6 feet apart.
4. The riser room, sprinkler system number 3 is missing the hydraulic plate

According to NFPA 13 (1999 edition) 8.6.3.4.1; "Unless the requirements of 8.6.3.4.2, 8.6.3.4.3, or 8.6.3.4.4 are met, sprinklers shall be spaced not less than 6 ft. (1.8 m) on center."

Based on observation during the Life Safety Survey and interviews with the maintenance Director, the facility failed to provide ashtrays and butt cans of a safe design in the designated smoking area this could result in fire, smoke, and fire gasses permeating the building and jeopardizing patients and staff.

Findings include:

During the facility tour with the maintenance Director on 02/09/2016 at 12:00 pm, it was observed that the facility had a designated employee smoking area but did not have the proper signage, butt cans, and ashtrays that were of the safe design in the smoking area in accordance with NFPA 101 (2000) 18.7.4 & 19.7.4. The maintenance Director advised he would order the required ashtrays, butt cans and proper signage.

Based on observation during the Life Safety Survey and interviews with the maintenance director, it was determined that the facility failed to maintain the kitchen hood system which would allow grease-laden vapors to build up in the seams resulting in a potential fire above the hood suppression system which could endanger the building occupants.

The Findings Include:

During the facility tour with the maintenance Director on 02/09/2016 at 1:35 pm, it was observed that the facility failed to maintain the kitchen hood system. The dietary kitchen hood system was observed to have caulk missing and falling out of the seams. An interview conducted with the maintenance Director who confirmed the findings.
Per NFPA 96 (1998 edition) 5.1.4.

Based on observation and interviews, 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.

The findings Include:

During the facility tour with the Maintenance Director on 02/09/2016 at 12:45 pm, the following was observed:

1. The sink in the old breakroom did not have a GFI receptacle.
2. The sink in the soiled linen room did not have a GFI receptacle.
3. That the alcohol based hand rub dispenser in the nurses station was mounted directly over a light switch.

The maintenance Director was shown the problem and confirmed the findings.

Per NFPA 70