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Based on record review and staff interview, the facility failed to provide regular inspections, testing and maintenance of fire and smoke door assemblies. In the event of a fire, this could lead to doors failing to perform as designed resulting in the spread of fire, smoke, and gasses endangering the occupants and staff of the building.

The findings include:

A record review and interview was conducted with the Maintenance Director on 9/13/23 at 10:30 a.m. The facility failed to produce documentation for the fire and smoke doors annual inspections. An interview was conducted with the Maintenance Director who concurred with the observations and confirmed the findings.


NFPA 101 (2012 edition) 19.7.6, 8.3.3.1
NFPA 80 (2010 edition) 5.2, 5.2.3, 5.2.4
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Based on record review and staff interview, the facility was not in compliance with National Fire Protection Association (NFPA) 101, by failing to maintain a generator fuel analysis including all required American Society for Testing & Materials (ASTM) fuel tests. Failure of the generator due to incomplete fuel tests could result in danger to the residents, staff, and other building occupants.

The findings include:

During record review with the Maintenance Director at 10:00 a.m. on 9/13/23, the generator inspection and maintenance log was reviewed for compliance. The current fuel test inspection report was requested. The facility was able to produce a current fuel test inspection report for the emergency standby power system. The fuel analysis was current, but did not include all the ASTM tests performed on the fuel. Only two of the eight required tests were completed on the fuel report. The Maintenance Director confirmed the findings and acknowledged the facility's non-compliance with the requirements.

Code: NFPA 101 (2018 Edition) Ch 4.6.12.4
NFPA 110 (2013) Ch 8.3.8

(Photographic Evidence Obtained)
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