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Based on observation made during the Fire & Life Safety survey tour, and interviews with Director of Plant Operations, 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(2012 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 Fire & Life Safety survey tour of the facility with the Director of Plant Operations on 03/13/2017 between 10am to 2pm, it was found that penetrations through the wall above the ceiling had not been fire stopped or smoke sealed. The following locations were observed to have penetrations:
1. Kitchen, penetrations in the ceiling
2. Phone room, penetrations in wall
3. Dietary Hall, above double self-closing doors, penetration in wall
4. Emergency room hallway, hole in fire doors, around door handle
5. Admission Office, penetration in wall next to copy machine
6. Emergency room lobby door, penetrations in door
7. Emergency room hallway door, penetrations in door frame
8. C.T. scan room, penetrations in wall and ceiling
9. Lab hallway, electrical room, penetrations in wall
10. Server room penetration in wall
11. Nurses station, air handler room, penetration in wall and ceiling


All locations were not properly protected with the required fire caulk. Director of Plant Operations was shown the penetrations and confirmed the findings.
According to NFPA 101(2012 edition) 8.3 and 19.3.7

Based on observation made during the Fire & Life safety tour, and interviews with Director of Plant Operations, the facility failed to ensure interior finish for rooms and spaces not used for corridors or exit ways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings, has a flame spread rating of Class A or Class B thus endangering occupants of the facility. (In fully sprinkled buildings, flame spread rating of Class A, Class B, or Class C may be continued in use within rooms separated in accordance with 19.3.6 from the access corridors.) NFPA 101 Life Safety Code (2012) 19.3.3.1, 19.3.3.2

The findings include:
During the Fire & Life Safety tour of the facility with the Director of Plant Operation between 10am and 2pm, it was observed that the facility failed to prohibit unapproved cork board on the wall of an office located in the Lab. The Administrator advised the board had been used to post information on for the Lab staff in the past. The Director of Plant Operations was present during the observation, and confirmed the findings.
The interior finish for rooms and spaces, not used for corridors and exit ways, shall have a flame spread rating as required; including exposed interior surfaces of buildings, such as, fixed or movable partitions, columns, and ceilings.
NFPA 101 (2012) 18.3.3.2.1 & 19.3.3.2.1

Based on document review during the Fire & Life Safety survey, and interviews with Director of Plant Operations, it was determined that the facility did not ensure the fire alarm system was inspected and tested as required. The facility failed to provide documentation that the fire alarm sensitivity tests had been done. This in the event of fire could delay or deny the fire alarm system to perform as required.

The findings are:
During the Fire & Life Safety document review of the facility with the Director of Plant Operations on 03/13/2017 between 10am to 2pm the facility failed to produce the fire alarm sensitivity report. The Director of Plant Operations called the Fire Alarm Company and was unable to produce a sensitivity test.
NFPA 101 (2012

Based on observation made during the Fire & Life safety tour, and interviews with Director of Plant Operations, 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 include:
During the Fire & Life Safety tour of the facility with the Director of Plant Operation between 10am to 2pm, sprinkler heads were observed in the following areas, to be in need of replacement:
1. Kitchen, 9 out of 9 sprinkler heads were dirty
2. Material Management painted sprinkler head
3. Housekeeping supply room corroded sprinkler head

The Director of Plant Operations 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 made during the Fire & Life Safety survey tour, 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 situation.

The findings Include:
During the Fire & Life Safety survey tour of the facility with the Director of Plant Operations on 03/13/2017 between 10am to 2pm, it was observed that several 1 hour rated Fire/Smoke doors were not closing properly:
1. Door to loading dock, not latching
2. Board room door, not latching
3. Dietary mop closet, door, not latching
4. Main kitchen door not latching
5. Detox hallway, room # 1, room has been re-purposed for storage and now needs a closure
6. Dietitian Office, door has a roller latch, needs to be replaced
7. Group room door not latching
8. Rooms 101,103, 104, & 120, all have roller latches and need to be replaced
9. Rear door to patient overflow, not latching
10. Nurses station, air handler room, need to remove the hasp
11. Physical therapy, door leading to main hallway not closing
12. Physical therapy room door not latching
13. Physical therapy exit door not latching
14. Emergency room, lobby door and hallway door both have slide locks on them that needs to be removed

The Director of Plant Operations was present during the observation, 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 document review during the Fire & Life Safety survey, and interviews with Director of Plant Operations, the facility failed to conduct and document the required annual Internal and External disaster drills. These drills increase the knowledge of staff of the action to take in an emergency situation and helps prevent confusion to occupants and staff in the event of an emergency.

The findings include:
During the Fire & Life Safety document review of the facility with the Director of Plant Operations on 03/13/2017 between 10am to 2pm, it was found that the annual Internal disaster drill had not been done. Each organizational cooperation entity shall implement two or more (Internal & External) specific responses of the emergency operations plan during each year. The Director of Plant Operations was present during the observation, and confirmed the findings. According to CMS, drills must be separated by 4 to 7 months. F.A.C. 59A-4

Based on document review during the Fire & Life Safety survey, and interviews with Director of Plant Operations, the facility failed to maintain fire and smoke dampers in accordance with NFPA 80. Failure to maintain fire dampers could result in the failure of these devices under fire and smoke conditions resulting in the spread of fire, smoke, and fire gasses throughout multiple smoke compartments thereby endangering the occupants of the building.

Findings include:
During the Fire & Life Safety document review of the facility with the Director of Plant Operations on 03/13/2017 between 10am and 2pm the facility failed to produce, evidence of fire and smoke damper maintenance and testing. The Director of Plant Operations was present during the observation, and confirmed the findings.
According to NFPA 80 (2010 edition) 19.4.1.1; "The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years."