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Based on observation made during the Fire & Life Safety tour of the facility, it was determined that the facility failed to maintain egress reliability of the exits. This condition could endanger building occupants in the event of a fire or other type emergency requiring evacuation.

Findings Include:
During the Fire & Life Safety tour of the facility with the Director of Maintenance on 01/17/2018 from 11am to 4pm, it was observed that the facility failed maintain egress reliability of the rear kitchen exit. The exit was obstructed with carts and other miscellaneous items stored in front of the exit door.
NFPA 101 (2012 edition) 7.1.3.2.2, 7.1.3.2.3 and 7.7
7.1.3.2.2 An exit enclosure shall provide a continuous protected path of travel to an exit discharge.
7.1.3.2.3* An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge.

Based on observation made during the Fire & Life Safety tour and interview with the Director of Maintenance, the facility failed to provide inspection, maintenance and testing of the fire sprinkler system in accordance with NFPA 25. Failure to inspect, maintain, and test system components could result in the system failing to perform as designed.

Findings include:
During the Fire & Life Safety tour of the facility with the Director of Maintenance on 01/17/2018 from 11am to 4pm, sprinkler heads were observed in the following areas, to be in need of replacement:
1. Room 112, corroded sprinkler head, which could result in this sprinkler head not performing as designed
2. Kitchen, mixed sprinkler heads, there were quick response heads mixed with high temperature heads, which could result in the sprinkler heads not performing as designed
3. Emergency room department, dirty sprinkler heads, which could result in the sprinkler heads not performing as designed

The Director of Maintenance was present during the observation, and confirmed the findings.
According to NFPA 25 (2011 edition) 5.2.1.1.1; "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage; and shall be installed in the correct orientation." and 5.2.1.1.2; "Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5) Loading, (6) Painting unless painted by the sprinkler manufacturer."

Based on observation made during the Fire & Life Safety tour and interview with the Director of Maintenance, 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.

Findings Include:
During the Fire & Life Safety tour of the facility with the Director of Maintenance on 01/17/2018 from 11am to 4pm, it was observed that several 1 hour rated Fire/Smoke doors were not closing properly.
1. Door # 111, a storage room, had a gap at the top of the door which could allow fire, smoke and fire gasses to enter the compartment
2. Door # 113, had a gap at the top of the door which could allow fire, smoke and fire gasses to enter the compartment
3. Door # 115, not latching, which could allow fire, smoke and fire gasses to enter the compartment
4. Kitchen door was not closing or latching which could allow fire, smoke and fire gasses to enter the corridor
5. Hallway 2, Patient Nutrition room, hole in door which could allow fire, smoke and fire gasses to enter the compartment

The Director of Maintenance was present during the observation, and confirmed the findings
NFPA 101, (2012 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 and interview with the Director of Maintenance, the facility failed to properly maintain the required Fire/Smoke barrier penetrations, which had not been fire stopped or smoke sealed per the requirements of NFPA 101(2012 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 Fire & Life Safety tour of the facility with the Director of Maintenance on 01/17/2018 from 11am to 4pm, it was found that penetrations through the wall above the ceiling had not been fire stopped or smoke sealed. The following locations were observed to have penetrations:
1. Penetration above the ceiling at the double doors between hallway 1 & 2.
2. Penetration around the sprinkler head in the clean linen room located, between hallway 1 & 2.
3. Penetration in wall in the soiled linen room located, between hallway 1 & 2
4. Penetration in wall in the housekeeping closet located between hallway 1 & 2
5. Penetration in wall in the storage room located next to door 111
6. Penetration in wall in the quality improvement director's office
7. Penetration in wall above the ice machine in the kitchen
8. Penetration in ceiling in the kitchen at the sinks
9. Penetration in the housekeeping room located in the kitchen, penetrations had been filled with an unapproved spray foam
10. Penetrations in camera room, penetrations had been filled with an unapproved spray foam

Maintenance was shown the penetrations and confirmed the findings.
According to NFPA 101(2012 edition) 8.4.4 & 8.4.4.1 and 19.3.7.6

Based on observation made during the Fire & Life Safety tour, the facility failed to maintain the exhaust system. Failure to maintain the exhaust system could result in environmental harm to residents and staff.

Findings Include:
During the Fire & Life Safety tour of the facility with the Director of Maintenance on 01/17/2018 from 11am to 4pm, it was found that the exhaust system was not working in the soiled linen room located on hallway 2.

Per NFPA 101 (2012 Edition) 19.5.2.1, 9.2.

Based on observation made during the Fire & Life Safety tour and interview with the Director of Maintenance, 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.

Findings Include:
During the Fire & Life Safety tour of the facility with the Director of Maintenance on 01/17/2018 from 11am to 4pm, it was observed that the facility failed to prohibit unapproved portable space heaters. Heaters were found in the following locations:
1. An unapproved portable space heater was located in room 114
2. An unapproved portable space heater was located in cardio room
3. An unapproved portable space heater was located in lab reception area
4. An unapproved portable space heater was located in business office

The Director of Maintenance was present during the observations, and confirmed the findings and removed the portable heaters.

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.

Based on observation made during the Fire & Life Safety tour and interview with the Director of Maintenance, the facility failed to provide a remote system alarm at a work site that was readily observable by personnel for monitoring the emergency power supply system (EPSS).

Findings Include:
During the Fire & Life Safety tour of the facility with the Director of Maintenance on 01/17/2018 from 11am to 4pm, it was observed that the facility's emergency power supply (EPS) annunciator panel was not installed in a continuously occupied location that was readily observed by staff. The annunciator was located at the nurses' station in an area that was not occupied from 11pm until 6am each night. The Director of Maintenance was present during the observation, and confirmed the findings.

NFPA 99, 6.4.1.1.17 A remote annunciator, storage battery powered, shall be provided to operate outside of the generator room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) Where a regular workstation will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 6.4.1.1.17(a) and (b) occur, but need not display these conditions individually

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.

Findings include:
During the Fire & Life Safety document review of the facility with the Director of Maintenance on 01/17/2018 from 11am to 1:30pm, no documentation was available for the Fuel Quality Check for the facility's diesel fuel.
The Director of Maintenance was present during the review, and confirmed the findings and advised the facility had not paid for the test and the lab would not send the report.
NFPA 110, 8.3.3, "A fuel quality check shall be done according to ASTM Standards on a yearly basis."