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The facility failed to ensure the corridor doors were provided with automatic latching hardware to keep the doors closed.

Observation determined numerous door leafs of double doors to multiple locations in the corridor were equipped with manual flush bolt latches rather than the required automatic latching hardware.

Failure to equip corridor doors with automatic latching hardware increases the risk of injury or death.

This deficiency affected numerous doors on the first and second floors throughout the building.

Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than one-half hour. 19.3.7.3

The facility failed to ensure one (1) of one (1) smoke barrier was at least one-half hour fire resistant and smoke resistant.

Observation determined unsealed openings around a sprinkler pipe, a conduit and multiple cables were not sealed with fire rated materials. Failure to maintain smoke barriers as required increases the risk of death or injury due to fire.

The deficiency affected two (2) of two (2) smoke compartments in the building.

Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 19.3.2.1

The facility failed to ensure doors to hazardous areas in fully sprinklered existing health care occupancies were equipped with self-closing/automatic latching hardware.

Observation determined the door to the Boiler Room failed to latch into its frame. The latch was repaired during the survey.

Failure to ensure doors to hazardous areas self-close and latch to the door frame increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous hazardous areas in the facility.

The facility failed to test the fire alarm system as required.

Review of fire alarm system test records indicated the following components of the fire alarm system were not documented as having been tested as required by NFPA 72, National Fire Alarm Code in the fire alarm test report of 11/11/2015.

1) Four (4) duct detectors.2) Two (2) smoke detectors.3) One (1) audio/visual device.4) One (1) auxiliary control.5) Five (5) door hold-open devices. Failure to test and maintain the fire alarm system as required increases the risk of death or injury due to fire.

The deficiency affected numerous required tests of the fire alarm system components during the last year. The fire alarm system serves the entire facility.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.

1) A functional test must be conducted on every required battery powered emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test must be conducted for 90-minute duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction.

The facility failed to ensure emergency lighting of at least 90-minute duration.

No documentation was available to indicate the battery powered emergency lights throughout the facility were tested for a minimum of 30 seconds at 30-day intervals and 90 minutes duration in the past year. Failure to test the emergency lighting system at 30-day intervals for not less than 30 seconds and test every battery-powered emergency lighting system annually for not less than 90 minutes increases the risk of injury or death. The deficiency affected emergency lighting in the entire facility.2) The facility failed to test and maintain the fire alarm system as required by NFPA 72, National Fire Alarm Code. No documentation was available to indicate the annual test of the fire alarm system was performed as required. No record was available of testing of the fire alarm system. Failure to test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire. This deficiency affected one (1) of one (1) fire alarm system. The fire alarm system serves the entire facility.3) Visual inspection frequencies and specific testing and maintenance frequencies for smoke detection systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods. Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years. The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with the manufacturer's specifications. Review of documentation and interview with staff determined the smoke detection system did not have sensitivity testing at frequencies in compliance with the minimum requirements of NFPA 72. No records were available to indicate the smoke detectors were sensitivity tested as required by NFPA 72. Failure to test the smoke detection system in accordance with NFPA 72 increases the risk of death or injury due to fire.This deficiency affected the entire building. 4) Compressed or liquefied gas cylinders in use or in storage shall be secured to prevent them from falling or being knocked over. This standard applies to the storage, use, and handling of compressed and liquefied gases in portable cylinders in all occupancies. NFPA 55 Standard for the Storage, Use, and Handling of Compressed and Liquefied Gases in Portable Cylinders, 1998 Edition, Section 6.6. The facility failed to ensure all compressed gas cylinders were secured to prevent falling or being knocked over. Observation determined two (2) of four (4) large CO2 cylinders were stored unsecured against the wall in the pool area with no mechanism in-place for securing them. Failure to secure compressed gas cylinders increases the risk of injury or death. This deficiency affected the entire pool area. 5) Only machinery and equipment used in conjunction with the function or use of the elevator shall be permitted in the elevator machine room. NFPA 9.4.2, 9,4.3 ASME/ANSI A17.1 Safety Code for Existing Elevators and Escalators, 2.7.2 Equipment in Machine Room 2.7.2.1 Equipment Permitted. The facility failed to ensure the Elevator Equipment Room was used only for elevator equipment.Observation determined the presence of combustible storage in the Elevator Equipment Room.Failure to prevent the storage of combustible storage in the Elevator Equipment Room increases the risk of injury and death.This deficiency affected the entire Elevator Equipment Room.

1) All Level 1 and Level 2 installations of an emergency generator must have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition. Ref: 2000 NFPA 101 Section 19.2.9.1, 7.9.2.3, 1999 NFPA 110 Section 3-5.5.6.

Observation determined there was no remote emergency stop switch for the emergency generator located outside of the Generator Room.

Failure to ensure the emergency generator was in compliance with NFPA 110, increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.

2) A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. NFPA 99 3-4.1.1.15

The facility failed to ensure the emergency generator was in compliance with NFPA 99, Standard for Health Care Facilities.

Observation determined there was no remote annunciator located outside of the Generator Room at a work site readily observable by personnel.

Failure to ensure the emergency generator was in compliance with NFPA 99 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.

The facility failed to ensure electrical wiring and electrical equipment met the requirements of NFPA 70, National Electrical Code. 19.5.1, 9.1.2

Observation determined there were numerous open electrical junction boxes in multiple locations in the facility.

Failure to ensure electrical wiring is in accordance with NFPA 70 increases the risk of death or injury due to fire.

The deficiency affected numerous components of the electrical system in the facility.

The facility failed to ensure the corridor doors were provided with automatic latching hardware to keep the doors closed.

Observation determined numerous door leafs of double doors to multiple locations in the corridor were equipped with manual flush bolt latches rather than the required automatic latching hardware.

Failure to equip corridor doors with automatic latching hardware increases the risk of injury or death.

This deficiency affected numerous doors on the first and second floors throughout the building.

Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than one-half hour. 19.3.7.3

The facility failed to ensure one (1) of one (1) smoke barrier was at least one-half hour fire resistant and smoke resistant.

Observation determined unsealed openings around a sprinkler pipe, a conduit and multiple cables were not sealed with fire rated materials. Failure to maintain smoke barriers as required increases the risk of death or injury due to fire.

The deficiency affected two (2) of two (2) smoke compartments in the building.

Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 19.3.2.1

The facility failed to ensure doors to hazardous areas in fully sprinklered existing health care occupancies were equipped with self-closing/automatic latching hardware.

Observation determined the door to the Boiler Room failed to latch into its frame. The latch was repaired during the survey.

Failure to ensure doors to hazardous areas self-close and latch to the door frame increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous hazardous areas in the facility.

The facility failed to test the fire alarm system as required.

Review of fire alarm system test records indicated the following components of the fire alarm system were not documented as having been tested as required by NFPA 72, National Fire Alarm Code in the fire alarm test report of 11/11/2015.

1) Four (4) duct detectors.2) Two (2) smoke detectors.3) One (1) audio/visual device.4) One (1) auxiliary control.5) Five (5) door hold-open devices. Failure to test and maintain the fire alarm system as required increases the risk of death or injury due to fire.

The deficiency affected numerous required tests of the fire alarm system components during the last year. The fire alarm system serves the entire facility.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.

1) A functional test must be conducted on every required battery powered emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test must be conducted for 90-minute duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction.

The facility failed to ensure emergency lighting of at least 90-minute duration.

No documentation was available to indicate the battery powered emergency lights throughout the facility were tested for a minimum of 30 seconds at 30-day intervals and 90 minutes duration in the past year. Failure to test the emergency lighting system at 30-day intervals for not less than 30 seconds and test every battery-powered emergency lighting system annually for not less than 90 minutes increases the risk of injury or death. The deficiency affected emergency lighting in the entire facility.2) The facility failed to test and maintain the fire alarm system as required by NFPA 72, National Fire Alarm Code. No documentation was available to indicate the annual test of the fire alarm system was performed as required. No record was available of testing of the fire alarm system. Failure to test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire. This deficiency affected one (1) of one (1) fire alarm system. The fire alarm system serves the entire facility.3) Visual inspection frequencies and specific testing and maintenance frequencies for smoke detection systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods. Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years. The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with the manufacturer's specifications. Review of documentation and interview with staff determined the smoke detection system did not have sensitivity testing at frequencies in compliance with the minimum requirements of NFPA 72. No records were available to indicate the smoke detectors were sensitivity tested as required by NFPA 72. Failure to test the smoke detection system in accordance with NFPA 72 increases the risk of death or injury due to fire.This deficiency affected the entire building. 4) Compressed or liquefied gas cylinders in use or in storage shall be secured to prevent them from falling or being knocked over. This standard applies to the storage, use, and handling of compressed and liquefied gases in portable cylinders in all occupancies. NFPA 55 Standard for the Storage, Use, and Handling of Compressed and Liquefied Gases in Portable Cylinders, 1998 Edition, Section 6.6. The facility failed to ensure all compressed gas cylinders were secured to prevent falling or being knocked over. Observation determined two (2) of four (4) large CO2 cylinders were stored unsecured against the wall in the pool area with no mechanism in-place for securing them. Failure to secure compressed gas cylinders increases the risk of injury or death. This deficiency affected the entire pool area. 5) Only machinery and equipment used in conjunction with the function or use of the elevator shall be permitted in the elevator machine room. NFPA 9.4.2, 9,4.3 ASME/ANSI A17.1 Safety Code for Existing Elevators and Escalators, 2.7.2 Equipment in Machine Room 2.7.2.1 Equipment Permitted. The facility failed to ensure the Elevator Equipment Room was used only for elevator equipment.Observation determined the presence of combustible storage in the Elevator Equipment Room.Failure to prevent the storage of combustible storage in the Elevator Equipment Room increases the risk of injury and death.This deficiency affected the entire Elevator Equipment Room.

1) All Level 1 and Level 2 installations of an emergency generator must have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition. Ref: 2000 NFPA 101 Section 19.2.9.1, 7.9.2.3, 1999 NFPA 110 Section 3-5.5.6.

Observation determined there was no remote emergency stop switch for the emergency generator located outside of the Generator Room.

Failure to ensure the emergency generator was in compliance with NFPA 110, increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.

2) A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. NFPA 99 3-4.1.1.15

The facility failed to ensure the emergency generator was in compliance with NFPA 99, Standard for Health Care Facilities.

Observation determined there was no remote annunciator located outside of the Generator Room at a work site readily observable by personnel.

Failure to ensure the emergency generator was in compliance with NFPA 99 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.

The facility failed to ensure electrical wiring and electrical equipment met the requirements of NFPA 70, National Electrical Code. 19.5.1, 9.1.2

Observation determined there were numerous open electrical junction boxes in multiple locations in the facility.

Failure to ensure electrical wiring is in accordance with NFPA 70 increases the risk of death or injury due to fire.

The deficiency affected numerous components of the electrical system in the facility.