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Based on observation the facility failed to provide documentation for inspection of doors.

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 1:00 pm to 4:20 pm on 1/24/2018 that documentation was not available for review for the following: Inspection of Doors in Means of Egress - Records - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7. Fire-rated door assemblies and certain other doors in the means of egress shall be tested annually or per an accepted performance-based evaluation schedule approved by the authority having jurisdiction, AHJ, per NFPA 80, 2010, Ch. 5.2. A written record of the inspections and testing shall be signed and kept for inspection by the AHJ. NFPA101

Based on observation the facility failed to follow adequate safety standards in the boiler room.

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 1:00 pm to 4:20 pm on 1/24/2018 that there were the following issues. They were:

Two one gallon cans of vacuum pump oil was stored in the boiler room.
65.206. Care of Boiler Room. (Adopted effective June 15, 2015, 40 TexReg 3121)
(b) The storage of flammable material or gasoline-powered equipment in the boiler room is prohibited.

Location: Small storage room across from room 232: The facility failed to maintain a minimum of 18" of space between the sprinkler head and stored materials. This sprinkler head is missing its required escutcheon plate.
"The clearance between the deflector and the top of storage shall be 18 inches or greater." - NFPA 13, 2010: 8.5.6.1.
"Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of the listed sprinkler assembly." -NFPA 13, 2010, 6.2.7.2

Based on observation the facility failed to properly label and identify the fire alarm circuit breaker.

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 1:00 pm to 4:20 pm on 1/24/2018 that there were the following issues. They were:
"The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL"" - NFPA 72, 2010: 10.5.5.2.2

Based on observation the facility failed to properly seal a fire wall penetration.

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 1:00 pm to 4:20 pm on 1/24/2018 that there were the following issues. They were:

Location: Area 2A: Rated double doors near room 216: Above doors and above ceiling tiles. There were some penetrations that were not properly sealed.

Location: Area 2A: Rated double doors near room 232: Above doors and above ceiling tiles. There was a gypsum board covering a hole. The facility failed to seal the edges of this gypsum board repair with a rated red sealant.

Based on observation the facility failed to provide adequate Risk Assessment documentation.

The inspector observed, while accompanied by the Plant Operations Manager during the hours of the inspection from 1:00 pm to 4:20 pm on 1/24/2018 that there were the following issues. They were: The facility failed to provide documentation for Risk Assessment per the following requirements: Risk Assessment: Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel, see Chapter 4 (NFPA 99). The facility must define its risk assessment methodology, implement the methodology, and document the results in relation to the risk categories contained in the NFPA99 Health Care Facilities Code. No particular risk assessment procedure is required. The facility will determined the procedure that most meets their needs within the requirement of the NFPA code. For additional information see the appendix of NFPA 99, A4.1 and A4.2.