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Based on observation and interview, the facility failed to provide separation from hazardous areas per the requirements of:

2012 NFPA 101, 19.3.2.1.3

Findings include:

On 09/13/2017, during a tour of the facility from 9:00 am to 2:45 pm, the Linen /Supply Room in the Gateway Extension (first floor) was observed to be over 50 sq. ft. with combustible materials, the two entry doors were observed without self-closing devices.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to prohibit the deep-fat fryer from being installed adjacent to cooking equipment with open surface flames per the requirements of:

2012 NFPA 101, 19.3.2.5.1
2012 NFPA 101, 9.2.3
2011 NFPA 96, 12.1.2.4, 12.1.2.5

Findings include:

On 09/13/2017 during a tour of the facility from 9:00 am to 2:45 pm, the surveyor observed the deep-fat fryer adjacent to the gas stove open flames, without spacing or a baffle.

A member of the maintenance staff when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain an Alcohol Based Hand Rub Dispenser (ABHR) per the requirements of:

2012 NFPA 101, 19.3.2.6* (8)

Findings include:

On 09/13/2017, during a tour of the facility from 9:00 am to 2:45 pm, the Alcohol Based Hand Rub Dispenser (ABHR)was observed installed above an ignition source (light switch) in the Emergency Overflow Room.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain the strobe devices for the fire alarm system per the requirements of:

2012 NFPA 101, 19.3.4.3.1
2012 NFPA 101, 9.6.3.5

Findings include:

On 09/13/2017, during a tour of the facility from 9:00 am to 2:45 pm, the fire alarm strobe device was observed not working during the testing of the fire alarm system at the Stairways Exit in the Gateway Extension (1st Floor).

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to install the portable fire extinguishers per the requirements of:

2012 NFPA 101, 19.3.5.12
2012 NFPA 101, 9.7.4.1
2010 NFPA 10, 6.1.3.8.1

Findings include:

On 09/13/2017, during a tour of the facility from 9:00 a.m. to 2:45 p.m., portable fire extinguishers were observed installed more than 5 ft. from the floor to the top of the fire extinguishers (approximately 68") in the following locations:

1. The Maintenance Storage Room on the 2nd Floor
2. The Basement Hallway near the Kitchen

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain the corridor doors per the requirements of:

42 CFR 483.90 (a) (1) (ii)
2012 NFPA 101, 19.3.6.3.10*

Findings include:

On 09/13/2017, during a tour of the facility from 9:00 am to 2:45 pm, the Storage Room corridor door, located across from the Doctors Lounge on the 2nd Floor failed to positive latch while testing.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating per the requirements of:

2012 NFPA 101, 19.3.7.3

Findings include:

On 09/13/2017, during a tour of the facility from 9:00 am to 2:45 pm, the smoke barrier near the Shower Room on the 2nd Floor Gerri Psych Unit was observed with an orange non-fire rated foam sealant that was used to seal a penetration in the smoke barrier.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to maintain the designated smoking area per the requirements of:

2012 NFPA 101, 19.7.4* (5)

Findings include:

On 09/13/2017, during a tour of the facility from 9:00 am to 2:45 pm, the designated smoking area was observed without an ashtray of noncombustible material.

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation and interview, the facility failed to provide documentation of testing the diesel generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, 8.3.8, 8.4.1, 8.4.2, and 8.4.2.3

Findings include:

On 09/14/2017, during a tour of the facility from 9:00 a.m. to 12:00 p.m., based on review of documentation and interview the facility failed to:

1. Test the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature OR under operating temperature conditions at not less than 30% of the nameplate kW rating OR provide an annual 1.5 hour supplemental load test at not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less 75% of the EPS nameplate KW rating for one continuous hour for a total test duration of not less than 1.5 continuous hours.

2. To have a fuel quality test performed at least annually using tests approved by ASTM standards.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to prohibit the use of extension cords per the requirements of:

2012 NFPA 99, 10.2.3.6 (3)
2011 NFPA 70, 400.8

Findings include:

On 09/13/2017, during a tour of the facility from 9:00 am to 2:45 pm, the following was observed:

1. The Med Surge Nutrition Room had a refrigerator plugged into an extension cord
2. The Home Health Care Office on the Second Floor had an extension cord in use

A member of the maintenance staff was present when this deficiency was identified.