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Based on observation,.The facility failed to maintain the fire doors in operational condition. It was found that 2 of 5 fire doors sampled failed to close and latch upon release. Fire doors which do not close completely can allow fire, heat, smoke, toxic fumes to penetrate an area which is to be protected.

The findings include:

During facility tour with the Director of Maintenance 12:45 pm on 6/04/2013, it was found that the latches on Fire Doors located in the (1) washroom hallway and (2) next to the Library were not completely closing and latching upon release from the magnetic holder. This was confirmed by the Director of Maintenance at that time. The Fire doors are not in accordance with NFPA 101, 19.2.2.2.6 and 7.2.1 NFPA 101 Life Safety Code (2006) 19.2.2.2

Based on document review, the facility failed to maintain proper inspection and testing of the Sprinkler system. Timely maintenance and inspection of the sprinkler system helps to ensure proper function of the system in time of emergency. Sprinkler malfunction could affect all persons within the facility.

The findings include:
During document review with the Director of Maintenance at 11:00am on 6/4/2013, it was found that facility had not done the 5-year internal obstruction inspection of the sprinkler system. According to NFPA 25 13.2.3.2, internal inspections shall be accomplished by examining the interior of the following points: 1- System valve. 2- Riser. 3- Cross Main. 4- Branch line.

Based on observations during the facility tour with Director of Maintenance, the facility failed to maintain the proper use of electrical strips (surge protectors) and /or extension cords. The use of surge protectors and extension cords allow the possibility of overloading the wiring dedicated to the outlet which can cause a fire hazard. Electrical fires can start in the walls or attic where it can go undetected, giving the hazard time to spread without being identified, placing the entire facility at risk.

The findings include:

During the facility tour with maintenance staff on 6/4/2013 at 1:00 pm, it was found that there were power strips/extension cords in offices throughout the facility with appliances attached. This is not in accordance with NFPA 99 - 3.2.1.2 or NFPA 1. Conducted an interview with the director of maintenance at that time and he confirmed the violations.

NFPA 99 - 3.2.1.2
2. Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles so as to avoid the need for extension cords or multiple outlet adapters.

NFPA 1 - 11.1.5
Extension cords shall not be used as a substitute for permanent wiring.