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Based on observation made during the Fire & Life Safety tour and interview with the Director of Maintenance, 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 facility Fire & Life Safety tour with the Director of Maintenance on 11/16/2017, between 8:00am and 1:30pm, a sprinkler head in the lab storage closet was observed to be corroded. The Director of Maintenance was shown the penetration 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 tour and interview with the Director of Maintenance, the facility failed to maintain fire extinguishers in accordance with NFPA 10 (for fire extinguishers) for proper signage and identification of fire extinguishers location. This could cause a delay in locating a fire extinguisher in an emergency situation.

Findings Include:
During the facility Fire & Life Safety tour with the Director of Maintenance on 11/16/2017, between 8:00am and 1:30pm it was found that fire extinguishers were located in flush mounted cabinets without signage. Flush mounted cabinets must be identified with signage which extends from the wall. The Director of Maintenance was present during the observation, and confirmed the findings
NFPA 101, 19.3.5.6 and 9.7.4.1, NFPA 10.

Based on observation made during the Fire & Life Safety tour and interview with the Director of Maintenance, 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.

Findings Include:
During the facility Fire & Life Safety tour with the Director of Maintenance on 11/16/2017, between 8:00am and 1:30pm, it was observed that several 1 hour rated Fire/Smoke doors were not closing properly.
1. Emergency room, room # 3, door going into the corridor, gap at top of door which could allow fire, smoke and fire gasses to enter the compartment
2. Lab storage closet, due to the large amount of combustibles in the room, door needs a closure on it
3. Doctor's office, door not closing properly
4. Administration Office, supply room, due to the large amount of combustibles in the room, door needs a closure on it

The Director of Maintenance was shown the penetrations 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 observation made during the Fire & Life Safety tour and interview with the Director of Maintenance, 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 include:
During the facility Fire & Life Safety tour with the Director of Maintenance on 11/16/2017, between 8:00am and 1:30pm, it was found that penetrations through the wall above the ceiling had not been fire stopped or smoke sealed in the following locations:
1. Emergency room, old Doctor's area, penetration in ceiling
2. Emergency room, room # 3, penetration in ceiling
3. X-ray Office on service hall, unapproved spray foam used to seal a penetration in wall around electrical outlet
4. Administration office supply room, penetration in wall
All locations were not properly protected with the required fire caulk. The Director of Maintenance was shown the penetrations and confirmed the findings.
According to NFPA 101(2012 edition) 8.3 and 19.3.7