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Based on observations, 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 tour of facility with Maintenance Director on 11/09/2015 at 1:30 pm, it was observed that several 1 hour rated Fire/Smoke doors were not closing properly, 1) smoke doors on the north corridor, 2) East corridor fire doors ,one door not closing and the other door dragging on the floor. The Maintenance Director was present when the doors were found and confirmed the findings. NFPA 101, (2000 edition,) Chapter 19, 19.3.6.3.2, "Doors shall be provided with a means for keeping the door closed that is acceptable to the AHJ."

Based on observation and interviews with staff, 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 facility tour with Maintenance Director, on 11/09/2015 at 1:35pm, it was found that penetrations through the wall above the ceiling have not been fire stopped or smoke sealed. The following locations were observed to have penetrations, (1) the air handler room, (2) east corridor over the fire doors. Both locations were not properly protected with the required fire caulk. Maintenance was shown the penetrations and confirmed the findings.
According to NFPA 101(2000 edition) 8.3.6 and 19.3.6

Based on observations made during tour of the facility, the automatic sprinkler system was not installed in accordance with NFPA 13. This in the event of fire could delay or deny extinguishment of a fire.
Findings include:
During the facility tour with Maintenance Director on 11/09/2015 at 2:25pm, observations of the facility automatic fire sprinkler system revealed that the facility had a mix of fusible link and chemical bulb standard response sprinkler heads in the maintenance area. Further investigation revealed that the chemical bulb replacement heads had a different temperature rating, and were different from the original sprinkler heads. Maintenance personal confirmed the observation. The automatic sprinkler system was not installed in accordance with NFPA 13.

Based on observations and staff interview, 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 Include:
During the facility tour with Maintenance Director on 11/09/2015 at 2:15pm, it was observed that the facility failed to prohibit unapproved portable space heaters. Heaters were found in the following locations; 1) Clinical Counselors office, Room# 8, 2) Room # W102, 3) Nursing office. Portable space-heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are me: (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 (2000) 18.7.8 & 19.7.8.

Based on observation, record review and interviews, the facility failed to maintain their emergency generator in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. This could result in loss of power to the facility in the event of a simultaneous failure of the local utility and the emergency generator thereby endangering the patients and occupants of the facility.

Findings include:
During document review with Maintenance Director on 11/05/2015, at 11:30 am, it was found that the facility failed to maintain their emergency generator in accordance with NFPA 110. The documents indicated that the generator had not had an annual test done since 2013. The facility administrator confirmed these findings. To insure reliability of the emergency power system, generator maintenance is a requirement of NFPA 110 (1999 edition) 8.3 Maintenance and Operational Testing.