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Based on observation and interviews with the Maintenance Director it was determined that the facility failed to maintain the kitchen hood system which would allow grease-laden vapors to build up in the seams resulting in a potential fire above the hood suppression system which could endanger the building occupants.

The Findings Include:

During the Fire & Life Safety tour of the facility with Maintenance Director on 12/05/2018, it was observed that the facility failed to maintain the kitchen hood system. The dietary kitchen was observed to have caulk missing and falling out of the seams. An interview conducted with the Maintenance Director confirmed the findings.

Per NFPA 96 (2011 edition) 5.1.4.

Based on the Fire & Life Safety document review with the Director of Maintenance on 12/05/2018, the facility failed to provide and maintain maintenance, inspection & testing of fire doors. This condition could allow Fire/Smoke to travel from one compartment to other compartments, thus endangering occupants of the facility.

Findings include:

During the Fire & Life Safety document review with the Director of Maintenance on 12/05/2018, it was observed that the facility failed to provide records of fire door Maintenance, Inspection & Testing.

Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC), NFPA 80 (2010 edition) 5.2, 5.2.3

Based on observation made during the Fire & Life Safety tour, 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 Fire & Life Safety tour of the facility with the Director of Maintenance on 12/05/2018, it was observed that the facility failed to prohibit an unapproved portable space heater in room # 201. The Director of Maintenance was present during the observation, and confirmed the findings and removed the portable heater.

Portable space-heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met: (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 (2012) 18.7.8 & 19.7.8.