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Based on observations made during tour of the facility, it was determined that the facility failed to utilize hazardous area enclosures where situations would require, and that the areas are properly equipped to protect from the specific hazards utilized.

Findings include:
While on tour of the facility with facility staff, the door to the dry goods storage for the kitchen was observed to be held open by a foot stop device mounted on the bottom of the door. The door was part of a rated enclosure and meant to be self closing. Failure of the door to self close in a fire could result in the spread of fire, smoke and fire gasses to the rest of the building, endangering the occupants. NFPA 101 (2000) 19.3.2.1

While on tour of the facility with facility staff, a soiled linen room was observed to have a door that was not self closing. Doors to hazardous rooms and areas are required to be self closing. NFPA 101 (2000) 19.3.2.1

Based on a review of the facility records, interviews with the staff, and observations made during tour of the facility, it was determined that automatic sprinkler system was not installed in accordance with NFPA 13, or maintained and tested in accordance with NFPA 25. This in the event of fire could delay or deny extinguishment of a fire.
Findings include:
While on tour of the facility with facility staff, sprinkler heads in the physical therapy room and the floor equipment storage room were observed to be lacking the color indicating fluid in the frangible bulbs of the sprinkler heads. The integrity of the bulbs being compromised could result in the delayed or possible lack of activation of the sprinkler head in a fire situation thereby endangering the occupants of the building. NFPA 25

While on tour of the facility with facility staff, the sprinkler heads in the walk in cooler and freezers in the kitchen were observed to be installed with ell (elbow) pipe fittings. Manufacturers specifications require dry sprinkler heads to be installed with a tee or coupling to insure proper operation of the sprinkler head upon activation. NFPA 25