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Based on observation and interview, the facility failed to maintain the fire door, which separated the non-sprinkled building from the sprinkled facility. The facility failed to assure the 2 hour fire rated separation between occupancies was complete. This deficient practice would allow fire, gasses and smoke to migrate between the two separate occupancies. The facility census was 13 patients.

Findings are:
Observations on 3-16-16 at 10:50 am and 11:27 am revealed:
1. The gap between 2 hour fire rated doors separating the Business occupancy from the Health Care occupancy were greater than 1/8 inch.
2. The 2 hour fire rated door in the Wood Shop, separating the non-sprinkled crawl space from the basement failed to close and latch within the door frame.

During an interview on 3-16-16 at 10:50 am and 11:27 am, Maintenance A confirmed the findings.

NFPA Standard:
Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies. 2000, NFPA 101, 8.2.3.2.1.

Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for a door in a 2-hour fire barrier shall have a 1 1/2-hour fire protection rating. 2000, NFPA 101, 8.2.3.2.3.1 (1).

Based on observation and interview, the facility failed to maintain an exit door within the vertical opening. This deficient practice would allow smoke and gasses within the stair tower which would delay egress during a fire emergency. The facility census was 13 patients.

Findings are:
Observations on 3-13-16 at 11:49 am revealed, the southeast stair door in the basement level failed to latch within the door frame when tested. A rug restricted the door.

During an interview 12-1-15 at 11:49 am, Maintenance A confirmed the findings.

NFPA Standard:
Requires a minimum one-hour fire resistance rating in shafts between floors. 2000 NFPA 101, 19.3.1.1 and 8.2.5.4

Based on observation and interview, the facility failed to maintain the doors to hazardous areas so they would to latch within their frame. This deficient practice would allow fire and smoke to migrate out of the hazard areas into the exiting corridors. The facility census was 13 patients.

Findings are:
Observations on 3-16-16 at 11:12 am and 12:42 pm revealed:
1. The Nursing Staff door, equipped with a self-closer, the failed to latch.
2. The latching mechanism on the " old stress test room " used as contractor storage room, was covered with tape so that the door would not latch.
3. The door to the Chiller Pump Room failed to close. The pipe above obstructed the door.

During an interview on 3-16-16 at 11:12 am and 12:42 pm Maintenance A confirmed the findings.

NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation, record review and interview, this facility failed to prohibit the use of more than one locking device on a door within a means of egress, to allow for quick and reliable exiting to a public way (an area of safety). The facility failed to provide signage on the access control doors and allowed a locking device on the access controlled door. This deficient practice would prohibit or delay egress during an emergency. The facility census was 13 patients.

Findings are:
Observation on 3-16-16 between 9:46 am and 11:58 am revealed:
1. The General X-ray/Radiation Room door was equipped with a thumb lock and door hardware to exit the room.
2. The Emergency Department access controlled exit doors failed to provide 41.5 inches of clear space when broke open.
3. The CT Scan door was equipped with a doorknob and a thumb turn deadbolt lock to exit the room.
4. The Fluora X-ray Room door was equipped with a thumb lock and door hardware to exit the room.
5. The Stair door across from Room 16, failed to provide delayed egress signage at the hardware and failed to be 1 inch.
6. The Repertory Therapy Office door was equipped with a thumb lock and door hardware to exit the room.
7. The Dining Room exit door was equipped with a thumb lock and door hardware to exit the room.
8. The Support Service Room door was equipped with a thumb lock and door hardware to exit the room.
9. The OR 1door was equipped with a thumb lock and door hardware to exit the room.

A record review of the facility floor plans on 3-16-16 between 9:46 AM and 11:58 AM indicated these doors were located within a required means of egress for use in the event of an emergency that required evacuation

During an interview on 3-16-16 between 9:46 am and 11:58 am, Maintenance A confirmed all the findings.

NFPA Standard:
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations. 2000 NFPA 101, 7.2.1.5.4*

A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

Doors located in the means of egress that are permitted to be locked shall have adequate provisions for the rapid removal of occupants such as remote control, the keying of all locks to keys carried by staff at all times, or knowledge of the code. Only one such locking device shall be permitted on each door. 2000 NFPA 101, 18/19.2.2.2.5

Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.


Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.
a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.
b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.
c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
d) On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 inch high and not less than 1/8 inch in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECOND.
2000 NFPA 101, 19.2.1 and 7.2.1.6.1

Based on documentation review and interview, the facility failed to hold fire drills at random times under varied conditions. When fire drills are held within the same time frame, they are not conducted under varied conditions. The deficient practice did not challenge facility staff under different times and conditions, which could impact staff response when faced with a real fire. The deficient practice affected all occupants. The facility census was 13 patients.

Findings are:
Fire drill documentation review on 3-16-16 at 12:40 pm revealed:
1. The first shift drills were conducted at 11:00am, 11:15am, 10:40am
2. The second shift drills were conducted at 3:00pm, 3:40pm, 4:00pm, 4:00pm 3:15pm
3. The third shift drill were conducted at 5:00am, 6:00am, 5:00am, 5:00am
4. 10 of 14 fire drills were conducted at the end of the month or within a few day of the end of the month.

During an interview on 3-16-16 at 12:40 pm, Maintenance A confirmed all the findings.

NFPA Standard:
The proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan. 2000 NFPA 101, 19.7.2.1

Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based on observation, documentation review and interview, the facility failed to assure that sprinklers escutcheons were installed. The facility failed to have the sprinkler system inspected quarterly by personnel who have developed competence through training and experience. This deficient practice could affect the operation of the sprinkler system and would affect all occupants. The facility census was 13 patients.

Findings are:
Observations on 3-16-16 at 10:20 am revealed a missing escutcheon on the sprinkler head in the X-ray/film storage room.

During an interview on 3-16-16 at 10:20 am, Maintenance A confirmed the findings.

Documentation review on 3-16-16 at 12:45 pm revealed, the facility had the sprinkler contractor do inspections on a yearly basis. The other three quarter inspections of the sprinkler system were conducted by the facility.

During an interview on 3-16-16 at 12:45 pm, Maintenance A confirmed the findings.

NFPA Standard:
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1

The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience. 1998 NFPA 25, 1-4.2

Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation and interview, the facility failed to assure the manual pull for the kitchen hood suppression system was secured to the wall. This deficient practice could delay the operation of the system in the event of a fire. The facility census was 13 patients.

Findings are:
Observations on 3-16-16 at 11:10 am revealed, the fasteners for the manual pull for the hood suppression system were not secured within the wall.

During an interview on 3-16-16 at 11:10 am, Maintenance A confirmed the findings.

NFPA Standard:
All actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, and fire-actuated dampers, shall be checked for proper operation during the inspection in accordance with the manufacturer ' s listed procedures. In addition to these requirements, the specific inspection requirements of the applicable NFPA standard shall also be followed. 1998 NFPA 96, 8-2.1

Based on documentation, observation and interview, the facility failed to provide a remote manual stop station, located outside the area of the generator, for the Level 1 emergency generator. This deficient practice had the potential to affect all occupants of the facility. The facility census was 13 patients.

Findings are:
Observation on 3-16-16 at 1:20 pm revealed, the facility failed to provide a remote manual shutdown for the generator.

During an interview on 3-16-16 at 1:20 pm, Maintenance A confirmed the facility failed to provide a manual shutdown and stated the generators were installed in 2005 and 2015.

NFPA Standard:
All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.
For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.1999 NFPA 110, 3-5.5.6*

Based on observation and interview, the facility failed to provide a cover for a electrical junction box. This deficient practice had the potential to cause electrical shock. The facility census was 13 patients.

Findings are:
Observation on 3-16-16 at 10:52 am revealed, an open junction box in the ceiling of the Janitors closet next to the Kitchen.

During an interview on 3-16-16 at 10:52 am, Maintenance A confirmed all findings.

NFPA Standard:
All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. 2000 NFPA 101, 9.1.2 and 1999 NFPA 70, 328.70 (C)

Based on observation and interview, the facility failed to maintain the fire door, which separated the non-sprinkled building from the sprinkled facility. The facility failed to assure the 2 hour fire rated separation between occupancies was complete. This deficient practice would allow fire, gasses and smoke to migrate between the two separate occupancies. The facility census was 13 patients.

Findings are:
Observations on 3-16-16 at 10:50 am and 11:27 am revealed:
1. The gap between 2 hour fire rated doors separating the Business occupancy from the Health Care occupancy were greater than 1/8 inch.
2. The 2 hour fire rated door in the Wood Shop, separating the non-sprinkled crawl space from the basement failed to close and latch within the door frame.

During an interview on 3-16-16 at 10:50 am and 11:27 am, Maintenance A confirmed the findings.

NFPA Standard:
Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies. 2000, NFPA 101, 8.2.3.2.1.

Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for a door in a 2-hour fire barrier shall have a 1 1/2-hour fire protection rating. 2000, NFPA 101, 8.2.3.2.3.1 (1).

Based on observation and interview, the facility failed to maintain an exit door within the vertical opening. This deficient practice would allow smoke and gasses within the stair tower which would delay egress during a fire emergency. The facility census was 13 patients.

Findings are:
Observations on 3-13-16 at 11:49 am revealed, the southeast stair door in the basement level failed to latch within the door frame when tested. A rug restricted the door.

During an interview 12-1-15 at 11:49 am, Maintenance A confirmed the findings.

NFPA Standard:
Requires a minimum one-hour fire resistance rating in shafts between floors. 2000 NFPA 101, 19.3.1.1 and 8.2.5.4

Based on observation and interview, the facility failed to maintain the doors to hazardous areas so they would to latch within their frame. This deficient practice would allow fire and smoke to migrate out of the hazard areas into the exiting corridors. The facility census was 13 patients.

Findings are:
Observations on 3-16-16 at 11:12 am and 12:42 pm revealed:
1. The Nursing Staff door, equipped with a self-closer, the failed to latch.
2. The latching mechanism on the " old stress test room " used as contractor storage room, was covered with tape so that the door would not latch.
3. The door to the Chiller Pump Room failed to close. The pipe above obstructed the door.

During an interview on 3-16-16 at 11:12 am and 12:42 pm Maintenance A confirmed the findings.

NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation, record review and interview, this facility failed to prohibit the use of more than one locking device on a door within a means of egress, to allow for quick and reliable exiting to a public way (an area of safety). The facility failed to provide signage on the access control doors and allowed a locking device on the access controlled door. This deficient practice would prohibit or delay egress during an emergency. The facility census was 13 patients.

Findings are:
Observation on 3-16-16 between 9:46 am and 11:58 am revealed:
1. The General X-ray/Radiation Room door was equipped with a thumb lock and door hardware to exit the room.
2. The Emergency Department access controlled exit doors failed to provide 41.5 inches of clear space when broke open.
3. The CT Scan door was equipped with a doorknob and a thumb turn deadbolt lock to exit the room.
4. The Fluora X-ray Room door was equipped with a thumb lock and door hardware to exit the room.
5. The Stair door across from Room 16, failed to provide delayed egress signage at the hardware and failed to be 1 inch.
6. The Repertory Therapy Office door was equipped with a thumb lock and door hardware to exit the room.
7. The Dining Room exit door was equipped with a thumb lock and door hardware to exit the room.
8. The Support Service Room door was equipped with a thumb lock and door hardware to exit the room.
9. The OR 1door was equipped with a thumb lock and door hardware to exit the room.

A record review of the facility floor plans on 3-16-16 between 9:46 AM and 11:58 AM indicated these doors were located within a required means of egress for use in the event of an emergency that required evacuation

During an interview on 3-16-16 between 9:46 am and 11:58 am, Maintenance A confirmed all the findings.

NFPA Standard:
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations. 2000 NFPA 101, 7.2.1.5.4*

A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

Doors located in the means of egress that are permitted to be locked shall have adequate provisions for the rapid removal of occupants such as remote control, the keying of all locks to keys carried by staff at all times, or knowledge of the code. Only one such locking device shall be permitted on each door. 2000 NFPA 101, 18/19.2.2.2.5

Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.


Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.
a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.
b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.
c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
d) On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 inch high and not less than 1/8 inch in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECOND.
2000 NFPA 101, 19.2.1 and 7.2.1.6.1

Based on documentation review and interview, the facility failed to hold fire drills at random times under varied conditions. When fire drills are held within the same time frame, they are not conducted under varied conditions. The deficient practice did not challenge facility staff under different times and conditions, which could impact staff response when faced with a real fire. The deficient practice affected all occupants. The facility census was 13 patients.

Findings are:
Fire drill documentation review on 3-16-16 at 12:40 pm revealed:
1. The first shift drills were conducted at 11:00am, 11:15am, 10:40am
2. The second shift drills were conducted at 3:00pm, 3:40pm, 4:00pm, 4:00pm 3:15pm
3. The third shift drill were conducted at 5:00am, 6:00am, 5:00am, 5:00am
4. 10 of 14 fire drills were conducted at the end of the month or within a few day of the end of the month.

During an interview on 3-16-16 at 12:40 pm, Maintenance A confirmed all the findings.

NFPA Standard:
The proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan. 2000 NFPA 101, 19.7.2.1

Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based on observation, documentation review and interview, the facility failed to assure that sprinklers escutcheons were installed. The facility failed to have the sprinkler system inspected quarterly by personnel who have developed competence through training and experience. This deficient practice could affect the operation of the sprinkler system and would affect all occupants. The facility census was 13 patients.

Findings are:
Observations on 3-16-16 at 10:20 am revealed a missing escutcheon on the sprinkler head in the X-ray/film storage room.

During an interview on 3-16-16 at 10:20 am, Maintenance A confirmed the findings.

Documentation review on 3-16-16 at 12:45 pm revealed, the facility had the sprinkler contractor do inspections on a yearly basis. The other three quarter inspections of the sprinkler system were conducted by the facility.

During an interview on 3-16-16 at 12:45 pm, Maintenance A confirmed the findings.

NFPA Standard:
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1

The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer ' s instructions. These tasks shall be performed by personnel who have developed competence through training and experience. 1998 NFPA 25, 1-4.2

Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation and interview, the facility failed to assure the manual pull for the kitchen hood suppression system was secured to the wall. This deficient practice could delay the operation of the system in the event of a fire. The facility census was 13 patients.

Findings are:
Observations on 3-16-16 at 11:10 am revealed, the fasteners for the manual pull for the hood suppression system were not secured within the wall.

During an interview on 3-16-16 at 11:10 am, Maintenance A confirmed the findings.

NFPA Standard:
All actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, and fire-actuated dampers, shall be checked for proper operation during the inspection in accordance with the manufacturer ' s listed procedures. In addition to these requirements, the specific inspection requirements of the applicable NFPA standard shall also be followed. 1998 NFPA 96, 8-2.1

Based on documentation, observation and interview, the facility failed to provide a remote manual stop station, located outside the area of the generator, for the Level 1 emergency generator. This deficient practice had the potential to affect all occupants of the facility. The facility census was 13 patients.

Findings are:
Observation on 3-16-16 at 1:20 pm revealed, the facility failed to provide a remote manual shutdown for the generator.

During an interview on 3-16-16 at 1:20 pm, Maintenance A confirmed the facility failed to provide a manual shutdown and stated the generators were installed in 2005 and 2015.

NFPA Standard:
All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.
For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.1999 NFPA 110, 3-5.5.6*

Based on observation and interview, the facility failed to provide a cover for a electrical junction box. This deficient practice had the potential to cause electrical shock. The facility census was 13 patients.

Findings are:
Observation on 3-16-16 at 10:52 am revealed, an open junction box in the ceiling of the Janitors closet next to the Kitchen.

During an interview on 3-16-16 at 10:52 am, Maintenance A confirmed all findings.

NFPA Standard:
All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. 2000 NFPA 101, 9.1.2 and 1999 NFPA 70, 328.70 (C)