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Based on observation made during the fire life safety tour of Building 1028, and interviews with Maintenance worker B, 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 facility tour of Building 1028 with Maintenance worker B., on 06/16/2016 , between 9am and 3:30pm ,it was observed that several 1 hour rated Fire/Smoke doors were not closing properly,
1) Resident room door # 346, not closing properly
2) Resident room door # 350, not closing properly
NFPA 101, (2000 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 of Building 1028, and interviews with Maintenance worker B, 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(2000 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 of Building 1028 Maintenance worker B, on 06/16/2016, between 9am and 3:30pm , 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) Penetration in wall above ceiling at door # 442
2) Penetration in wall above ceiling at door # 448
All 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 and 19.3.7

Based on observation made during the fire life safety tour , the facility failed to provide inspection, maintenance and testing of the fire sprinkler system. Failure to inspect, maintain, and test system components could result in the system failing to perform as designed thereby endangering the occupants of the building.
The findings Include:
During the facility tour of Building 1028 Maintenance worker B., 06/16/2016, between 9am and 3:30pm, it was observed that several sprinkler heads were in need of cleaning in the following areas.
1) Room # 445, sprinkler cover missing
2) Room # 401, dirty sprinkler head
3) Room # 301, dirty sprinkler head
4) Third floor lobby, dirty sprinkler heads
5) Room # 243, dirty sprinkler heads
All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 (1999 edition Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems).
NFPA 101 Life Safety Code (2000 edition) 18.3.5 & 19.3.5 & 9.7.5.

Based on observation and interview with the maintenance director, the facility failed to properly store compressed medical gas cylinders (oxygen) in accordance with NFPA 99 (1999 edition) 11.3.2.1. Improper storage of medical gas cylinders could result in the rupture of the cylinders and subsequent accelerated development of fire, smoke and fire gases in a fire situation.

Findings include:
During the facility tour with fire inspector and maintenance worker on 06/16/2016 starting at 9:30 am, the following was observed:
1) Room 120 has O2 bottles not secured and next to electrical outlet.
2) Room 206A has O2 bottles not secured.
These findings were verified by the maintenance director at the times observed.

Based on document review, the facility failed to maintain the annual fuel quality test for the generator. This could result in loss of power to the emergency generator thereby endangering the patients and occupants of the facility. Proper maintenance and inspection of the generator helps to ensure proper functioning in an emergency situation.

The findings include:
During document review and interview with Aramark Assistant Director, on 06/13/2016 at 1030am it was found that the Fuel Quality Check for the facilities Diesel Fuel had not been done; last test was done in May of 2015. Aramark Assistant Director advised he would have the test done as soon as possible.
NFPA 110, 8.3.3, "A fuel quality check shall be done according to ASTM Standards on a yearly basis."