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Based on observation and staff interview it was determined the facility failed to maintain continuous egress free of all obstructions to full use in case of emergency in accordance with NFPA (National Fire Protection Association) 101, 19.2.1. (Census: 127).

Findings include:

1. A tour of the facility on 11/30/16 at 2:15 p.m. revealed there were clean linen carts being stored in the egress corridor between environmental services and decontamination. There were a total of thirteen (13) carts being stored on both sides of the corridor. The clean linen storage room was full and there was no other location to store the carts.

2. The Facility Manager was present on 11/30/16 at 2:15 p.m. and agreed the corridor was being used as storage.

Based on observation and staff interview it was determined the facility failed to maintain time-delay exit locks in accordance with NFPA (National Fire Protection Association) 101, 19.2.2.2.4. (Census: 127).

Findings include:

1. During a tour of the faciliy on 11/30/16 at 10:06 a.m., the 5th floor North egress time delay to the stairwell failed to open.

2. During a tour of the facility on 11/30/16 at 10:50 a.m., the 4th floor East egress time delay to the stairwell failed to open.

3. The delay egress time delay was discussed with the Facility Manager on 11/30/16 at 11:00 a.m. and he agreed the time-delay devices were not working properly. The time-delay devices were deactivated at the time of survey, allowing emergency egress, and then repaired before the exit interview.

Based on observation and staff interview it was determined the facility failed to maintain the sprinkler piping free from loading in accordance with NFPA 25 (National Fire Protection Association), and NFPA 13 (Census: 127).

Findings include:

1. An inspection above the suspended ceiling on the 8th floor and near the community coordinator's office on 11/30/16 at 8:28 a.m. revealed low voltage wiring draped across the sprinkler piping.

2. An inspection above the suspended ceiling on the 7th floor and behind the nurse station on 11/30/16 at 9:10 a.m. revealed low voltage wiring draped across the sprinkler piping.

3. An inspection above the suspended ceiling on the 6th floor and behind the nurse station on 11/30/16 at 9:24 a.m. revealed low voltage wiring draped across the sprinkler piping.

4. An inspection above the suspended ceiling on the 5th floor and behind the nurse station on 11/30/16 at 10:26 a.m. revealed low voltage wiring draped across the sprinkler piping.

5. An inspection above the suspended ceiling on the 4th floor and behind the nurse station on 11/30/16 at 11:02 a.m. revealed low voltage wiring draped across the sprinkler piping.

6. An inspection above the suspended ceiling on the 3rd floor and near Care Management on 11/30/16 at 11:44 a.m. revealed low voltage wiring draped across the sprinkler piping.

7. The above findings were discussed with the Facility Manager on 11/30/16 who agreed the wires would need removed from the sprinkler piping.

Based on document review and staff interview it was determined the facility failed to conduct fire drills at varied times in accordance with NFPA (National Fire Protection Association) Life Safety Code 101 (Census: 127).

Findings include:

1. Review of records on 11/28/16 at 12:30 p.m. revealed first shift fire drills were conducted at 2:29 p.m. and 3:00 p.m. on the first and second quarters as well as 12:52 p.m. and 1:17 p.m. on the fourth quarter. Second shift fire drills were conducted at 1:27 p.m. and 1:40 p.m. on the 2nd and 4th quarters. Third shift fire drills were conducted at 4:01 a.m., 4:00 a.m., 3:33 a.m., 3:40 a.m., 3:38 a.m., and 4:00 a.m. on all four quarters. Third shift drills were also conducted at 1:45 a.m. and 1:44 a.m. on the 2nd quarter.

2. The Facility Manager was present on 11/28/16 at 12:30 p.m. and agreed this deficiency would need to be corrected.

Based on observation and staff interview it was determined the facility failed to maintain the electrical wiring in accordance with NEC (National Electric Code) and NFPA (National Fire Protection Association) 70 & 99 (Census: 127).

Findings include:

1. A tour of the Radiology Department on the 1st floor on 11/30/16 at 3:00 p.m. revealed an electrical receptacle in room A within six (6) feet of a sink and without ground fault protection.

2. A tour of the Radiology Department on the 1st floor on 11/30/16 at 3:02 p.m. revealed an electrical receptacle in room B within six (6) feet of a sink and without ground fault protection.

3. The above findings were discussed with the Facility Manager on 11/30/16 who agreed the above mentioned receptacles would need to be changed.

Based on document review and staff interview it was determined the facility failed to perform testing as required per NFPA (National Fire Protection Association) 99 on the line isolation monitors (Census is 127).

Findings include:

1. During document review on 11/30/16 at 2:00 p.m., no evidence could be provided to support the testing of the line isolation monitors.

2. The Facility Manager was present on 11/30/16 at 2:00 p.m. and agreed the testing has not been performed.

Based on document review and staff interview it was determined the facility failed to maintain the emergency generator in accordance with NFPA (National Fire Protection Association) 110 (Census: 127).

Findings include:

1. Document review on 11/30/16/ at 3:00 p.m. revealed no evidence could be found of testing the generator's battery electrolyte levels.

2. The Facility Manager was present on 11/30/16 at 3:00 p.m. and agreed the electrolyte levels were not being tested.