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National Fire Protection Association (NFPA) 101, Life Safety Code (2012 Edition)
19.2.5.4* Intervening Rooms or Spaces. Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.
19.2.10 Marking of Means of Egress.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.
19.2.10.2 Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons.
19.2.10.3 Where the path of egress travel is obvious, signs shall not be required at gates in outside secured areas.

7.1.3.2.2 An exit enclosure shall provide a continuous protected path of travel to an exit discharge.
7.5.1.2 Corridors shall provide exit access without passing through any intervening rooms other than corridors, lobbies, and other spaces permitted to be open to the corridor, unless otherwise provided in 7.5.1.2.1 and 7.5.1.2.2.

7.7.1* Exit Termination. Exits shall terminate directly at a public way or at an exterior exit discharge, unless otherwise provided in 7.7.1.2 through 7.7.1.4.
7.7.1.1 Yards courts, open spaces, or other portions of the exit discharge shall be of the required width and size to provide all occupants with a safe access to a public way.

7.7.3 Arrangement and Marking of Exit Discharge.
7.7.3.1 Where more than one exit discharge is required, exit discharges shall be arranged to meet the remoteness criteria of 7.5.1.3.
7.7.3.2 The exit discharge shall be arranged and marked to make clear the direction of egress travel from the exit discharge to a public way.

7.10.2 Directional Signs.
7.10.2.1* A sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Based on document review, observation, and interview, the facility failed to ensure that all exits terminated at a public way; discharges were arranged and marked to make clear the direction of egress travel from the exit discharge to a public way; and failed to provide exit access without passing through any intervening rooms.

Findings include:

On 08/27/2020, observation revealed the facility installed exit signs on both the internal side and external side of doors leading from buildings to a locked courtyard and directed the egress path from the courtyard through the same or another building before it terminated at a public way. A review of the facility's emergency egress floor plans revealed that the path of egress led people into the courtyard or to a public way, but did not indicate that egress required reentry into any building before terminating at a public way. The following buildings and paths of egress were affected:

1) Rawson Neal Complex
a) The door leading from the courtyard to the southwest entrance of unit A was marked with an exit sign that designated an egress path through unit A before it terminated at a public way.
b) The door leading from the courtyard to the south entrance unit B was marked with an exit sign that designated an egress path through unit B before it terminated at a public way.
c) The door leading from the courtyard to the west entrance to unit D was marked with an exit sign that designated an egress path through unit D before it terminated at a public way. There was not an exit sign posted on the internal side of the doorway that indicated a path of egress into and through the courtyard as designated on the facility's emergency egress floor plans.
d) The door leading from the courtyard to the west corridor and into unit D was marked with an exit sign that designated an egress path through the unit D before it terminated at a public way.
e) The door leading from the courtyard to southeast entrance to unit E was marked with an exit sign that designated an egress path through unit E before it terminated at a public way.
f) The door leading from the corridor into room A109 was marked with an exit sign with a directional arrow directing the path of egress from the corridor and through room A109 before it terminated at a public way. The door located at the northwest side of room A109 was not marked by an exit sign but was designated on the facility's floor plans as the path of egress from within room A109.
g) The exit sign located above the exit at room B100 was obstructed by the exit sign that directed the egress path through room A109. This exit was the one of four emergency exits designated as the path of egress leading from unit B to the parking lot.
h) The facility's emergency egress emergency floor plans directed the path of egress from within the courtyard to an exit door located between units A and H. The exit was marked with an illuminated exit sign but could not be visualized from all areas within the courtyard. The path of egress was not apparent from the areas of the courtyard located between units D through H.

2) Building 3a
a) The right exit (when facing the south patio) was marked with an exit sign and directed the egress path to a courtyard. The courtyard had two gates that lead to a public way, but both gates were locked with pad-locks that required a special key for opening. Adddionally, the facility installed a sign on the external side of the same door that stated "Exit Only". This sign was not consistent with the facility's emergency egress floor plan path of egress.
b) The left exit (when facing the south patio) was marked with a "No Exit" sign. This door was identified as an emergency exit on the facility's floor plan but is not marked with an illuminated exit sign.
c) The exit leading from Dayroom 30 to the west courtyard was designated as an emergency exit on the facility's emergency egress floor plans but was not marked with an illuminated exit sign. The facility's emergency egress floor plans indicated the path of egress was directed through the west courtyard with two locked gates that required a special key for opening.

During an interview, the Maintenance Assistant indicated that keys to the locked courtyards in building 3a were maintained by maintenance staff due to the building being unoccupied at the time of the survey.

All observations were made in the presence of the Maintenance Assistants and were acknowledged by the Director of Quality Assurance and Performance Improvement during the exit conference.

National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (2011 Edition).

11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every six months.

11.2.4* Fusible links of the metal alloy type and automatic sprinklers of the metal alloy type shall be replaced at least semiannually except as permitted by 11.2.6 and 11.2.7.

11.4* The entire exhaust system shall be inspected for grease buildup by a proper trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with table 11.4.

Table 11.4 Schedule of Inspection for Grease Buildup
System serving solid fuel cooking operations - Monthly
Systems servicing high-volume cooking operations, such as 24-hour cooking, charbroiling, or wok cooking - Quarterly
Systems serving moderate-volume cooking operations - Semiannually
Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers - Annually

11.6. Cleaning of Exhaust Systems
11.6.1 Upon inspection, if the exhaust system is found to be contaminated with deposits from grease-laden vapors, the contaminated portions of the exhaust system shall be cleaned by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction.
11.6.2* Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned and remove combustible contaminants prior to surfaces becoming heavily contaminated with grease or oily sludge.

Based on document review, interview and observation, the facility failed to ensure that: 1) the kitchen hood fire suppression system was serviced and fusible links were replaced every six months and 2) the entire kitchen exhaust system was inspected and cleaned semi-annually in accordance with NFPA 96.

Findings include:

Kitchen Hood Fire Suppression System Inspection
1) On 08/25/2020, document review revealed the facility failed to retain documentation as evidence the kitchen hood fire suppression system was serviced and fusible links were replaced every six months. No inspection tag was affixed to the kitchen hood fire suppression system. The facility provided a vendor report that indicated the hood suppression system was last serviced on 08/01/2019.

Kitchen Exhaust Systems Cleaning
2) Document review and observation revealed the facility exceeded the quarterly periodicity requirement for inspection and cleaning of the entire kitchen exhaust systems between 07/30/2019 and 12/23/2019 (4 months and 23 days).

The above deficiencies were acknowledged by the Director of Quality Assurance and Performance Improvement (QAPI) during the exit conference.

National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (2010 Edition)
10.18.3 Records.
10.18.3.1 A complete record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter.
10.18.3.2 The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.
10.18.3.3 If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year.

10.19* Impairments
10.19.1 The system owner or their designated representative shall be notified when a fire alarm system or part thereof is impaired. Impairments to systems shall include out-of-service events.
10.19.2 A record shall be maintained by the system owner or designated representative for a period of 1 year from the date the impairment is corrected.
10.19.3* Where required, mitigating measures acceptable to the authority having jurisdiction shall be implemented for the period that the system is impaired.
10.19.4 The system owner or owner's designated representative shall be notified when an impairment period is completed or discontinued.

14.2.1.2 Impairments.
14.2.1.2.1 The requirements of Section 10.19 shall be applicable when a system is impaired.
14.2.1.2.2 System defects and malfunctions shall be corrected.
14.2.1.2.3 If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.

Table 14.4.5.6. (d) Sealed lead-acid type batteries. required testing:
(1) Charger test (Replace battery within 5 years after manufacture or more frequently as needed) - Initial/Reacceptance & Annually
(2) Discharge test (30 minutes) - Initial/Reacceptance & Annually
(3) Load voltage test - Initial/Reacceptance & Semiannually

14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.
Table 14.4.5.15* Initiating Devices
(h) System smoke detectors - Functional Test - Initial/Reacceptance and Annually
4.4.5.3.1 Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.

Based on document review, observation, and interview the facility failed to 1) retain a complete record of the inspection, testing, and maintenance completed on each of the fire alarm control panel components and initiating devices; 2) correct all deficiencies in a timely manner; 3) perform annual functionality testing of each building's smoke detectors; and 4) perform smoke detector sensitivity tests every 2 years as required.

Findings include:

1) On 08/25/2020, document review revealed the facility did not have records as evidence the fire alarm control panels and manual initiating devices were inspected, tested, and maintained within the previous 12 months for all buildings surveyed. Documentation was requested but was not provided prior to completion of the survey.

2) During the facility tours 08/25/2020 through 08/27/2020, observation revealed four of the facility's fire alarm control panels failed to pass the battery load voltage test on 05/01/2020. The following Fire Alarm Control Panels were affected:

a) Rawson Neal Complex - Information/Technology (IT) Room E166 - The vendor tag stated "DEFICIENT" due to battery failure.
b) Rawson Neal Complex - IT Room H166 - The vendor tag stated "DEFICIENT" due to battery failure.
c) Stein Building - Main Control Room - The vendor tag stated "DEFICIENT" due to "batteries at 60%."
d) Building 1 - Fire Alarm Room - The vendor tag stated "DEFICIENT" due to battery failure.

During an interview, the Maintenance Assistant indicated that the batteries were on order, but had not been received. Documentation of the vendor's report of inspection and testing with corrective actions were requested but were not provided prior to completion of the survey.

3) Document review revealed the facility did not retain documentation as evidence all smoke detectors received annual functionality testing. All buildings were affected. Documentation was requested but was not received prior to completion of the survey.

4) Document review revealed the facility did not retain documentation as evidence smoke sensitivity tests were performed on all installed smoke detectors. All buildings were affected. Documentation was requested but was not received prior to completion of the survey.

All observations were made in the presence of the Maintenance Assistants. All deficiencies were acknowledged by the Director of Quality Assurance and Performance Improvement (QAPI) during the exit conference.

Based on document review, the facility failed to establish a policy that addressed the evacuation of the building or that an approved fire watch would be provided in the event the building's fire alarm system was out of service for more than 4 hours in a 24-hour period.

Findings include:

On 08/25/2020, document review revealed the facility failed to establish a policy that addressed the evacuation of the Rawson Neal Complex; building 3a; the dietary services building; the dietary storage building; and the Stein Building, or the provision of a fire watch in the event fire alarm systems were out of service for more than 4 hours in a 24-hour period. The facility's fire watch policy was requested but was not provided prior to completion of the survey.

Note: See Citation 0354 for evacuation and fire watch requirements that addressed the loss of the facility's fire sprinkler system.

The above deficiency was acknowledged by the Director of Quality Assurance and Performance Improvement (QAPI) during the exit conference.

National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection Systems (2011 Edition)

4.3 Records
4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.
4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
4.3.3* Records shall be maintained by the property owner.
4.3.4 As-built system installation drawings, hydraulic calculations, original acceptance test records, and device manufacturer's data sheets shall be retained for the life of the system.
4.3.5 Subsequent records shall be retained for a period of 1 year after the next inspection, test, or maintenance of that type required by the standard.

5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Table 5.1.1.2 - Inspection - Obstruction, internal inspection of piping - 5 years

5.2* Inspection
5.2.1 Sprinklers
5.2.1.1* Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical Damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)* Loading
(6) Painting unless painted by the manufacturer

5.2.1.1.4 Any sprinklers shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.

NFPA 13, Standard for the Installation of Sprinkler Systems (2010 Edition)
6.2.9.7 A list of the sprinklers installed in the property shall be posted in the sprinkler cabinet.
6.2.9.7.1* The list shall include the following:
(1) Sprinkler Identification Number (SIN) if equipped; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating
(2) General description
(3) Quantity of each type to be contained in the cabinet
(4) Issue or revision date of the list

Based on observation and document review, the facility failed to ensure that the installed automatic fire sprinkler system was inspected, tested, and maintained in accordance with NFPA 25.

Findings include:

1) On 08/25/2020, document review revealed the facility did not maintain records as evidence that all installed fire sprinklers were inspected on an annual basis. A copy of this documentation was requested but was not provided prior to survey completion.

2) On 08/25/2020, observation revealed the facility failed to ensure that a list of the sprinklers installed on the property were maintained in or on the sprinkler cabinets in the following locations:

A) Rawson Neal Complex
i) Fire Riser Room A
ii) Fire Riser Room D
iii) Fire Riser Room F
iv) Fire Riser Room H

B) Dietary Services Building - Fire Riser Room

C) Dietary Storage Building- Fire Riser Room

D) Stein Building - Fire Riser Room (behind elevator on first floor)

3) On 08/27/2020, observation revealed the facility failed to ensure that a copy of NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems was maintained in the Fire Riser Room or on the premises of the Stein Building.

4) On 08/27/2020, observation revealed the facility failed to ensure that an inspection of the internal fire sprinkler piping for obstructions was performed on the fire sprinkler system installed in the Dietary Storage Building within the previous five years. The vendor tag affixed to the fire riser indicated that the last 5-year obstruction inspection was performed on 06/23/2015. The 5-year obstruction test was overdue by two months and six days at the time of survey completion.

5) During the facility tours conducted 08/25/2020 through 08/27/2020, the following locations were observed with automatic fire sprinkler deficiencies:

A) Rawson Neal Complex:
i) Room (Rm) C175 - Corroded fire sprinkler
ii) Rm C157 - Rust and verdigris on the fire sprinkler located above the third bathroom stall
iii) Rm C156 - Dirt build up on the fire sprinkler
iv) Rm C154 - Rust and verdigris on the fire sprinkler
v) Rm C152 - Rust on the fire sprinkler
vi) Rm D161 - Excessive dust on two sprinklers above the restroom sinks
vii) Rm D123 - Paint overspray on the sprinkler above the first bathroom stall
viii) Rm D122 - Excessive dust on the sprinkler above the second bathroom stall
ix) Rm E175 - A 1/4 inch gap was observed between the sprinkler escutcheon and the ceiling
x) Rm E123 - Excessive dust on the sprinkler above the restroom sink
xi) Unit E Laundry Room (E124) - A 1/4 inch gap was observed between the sprinkler escutcheon and the ceiling
xii) Rm F120 - A yellow substance (possibly paint or caulk) coated the fire sprinkler assembly
xiii) Rm H103 - A 1/4 inch gap was observed between the sprinkler escutcheon and the ceiling

B) Dietary Services Building:
i) Excessive dust was observed on the sprinkler in the walk-in dairy refrigerator
ii) Excessive dust was observed on the sprinkler in the walk-in produce refrigerator
iii) Two sprinklers located in the dish washing area were observed with excessive dust
iv) One sprinkler in the dish washing area was observed with a 1/4 inch gap between the sprinkler escutcheon and the ceiling
v) Rust and verdigris was observed on the fire sprinkler above the preparation sink

All observations were made in the presence of the Maintenance Assistants and acknowledged by the Director of Quality Assurance and Performance Improvement (QAPI) during the exit interview.

Based on documentation review, the facility failed to establish a policy that addressed the evacuation or provision of an approved fire watch in buildings or portions of buildings in the event the fire sprinkler system was out of service for more than 10 hours in a 24 hour period.

Findings include:

On 08/25/2020, document review revealed the facility had not established a policy that addressed the evacuation of the Rawson Neal Complex; building 3a; the dietary services building; the dietary storage building; and the Stein Building, or the provision of a fire watch in the event that the building's fire sprinkler system was out of service for more than 10 hours in a 24-hour period. The facility's fire watch policy was requested but was not provided prior to completion of the survey.

Note: Citation 0346 addressed evacuation and fire watch requirements in the event that fire alarm systems were out of service.

The above deficiency was acknowledged by the Director of Quality Assurance and Performance Improvement (QAPI) during the exit conference.

National Fire Protection Association (NFPA) 101, Life Safety Code (2012 Edition)
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
39.3.5 Extinguishing Requirements. Portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1.
9.7.4.1 Where provided by the provision of another section of the Code, portable fire extinguishers shall be selected, installed, and inspected in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers (2010 Edition)
6.1.3.8 Installation Height
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.4 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.
6.1.3.8.2 Fire extinguishers having a gross weight greater than 40 lbs (18.4 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor.
6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable extinguisher and the floor be less than 4 in. (102 mm).

7.2 Inspection.
7.2.1 Frequency
7.2.1.1* Fire extinguishers shall be manually inspected when initially placed in service.
7.2.1.2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals.
7.2.2. Procedures. Periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items:
(1) Location in designated place
(2) No obstruction to access or visibility
(3) Pressure gauge reading or indicator in the operable range or position
(4) Fullness determined by weighing or hefting for self-expelling type extinguishers, cartridge operated extinguishers, and pump tanks
(5) Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
(6) Indicator for nonrechargeable extinguishers using push-to-test pressure indicators

7.3* Maintenance.
7.3.1 Frequency.
7.3.1.1 All Fire Extinguishers.
7.3.1.1.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification.

Based on document review, observation, and interview the facility failed to ensure that all portable fire extinguishers (PFEs) were 1) inspected at a minimum of 30-day intervals; 2) subjected to maintenance at intervals of not more than 1 year; and 3) were installed as required.

Findings include:

1) On 08/25/2020, document review and comparison of vendor inspection and maintenance tags revealed the facility failed to perform monthly inspections on all fire extinguishers located in the Rawson Neal Complex, the dietary services buildings, the dietary storage building, building 3a, the Stein Building, and building 1 during July 2019, September 2019, November 2019, and March 2020.

2) Document review revealed the facility failed to ensure that annual maintenance was performed on all PFEs located in the Rawson Neal Complex, the dietary services building, the dietary storage building, building 3a, the Stein Building, and building 1. All fire extinguisher documents indicated that all PFEs were last inspected between 8/23/2019 and 8/28/2019. Per the Maintenance Assistant, the facility had not scheduled annual maintenance and maintenance was not performed prior to completion of the survey.

3) On 08/27/2020, observation and measurement revealed the facility failed to ensure that PFEs were installed and maintained as required. The following deficiencies were isolated to building 1:

a) The PFE in the fire panel room was sitting upright on the floor, unsecured, and beneath its mounting bracket. The Maintenance Assistant attempted to secure its mounting bracket, however the bracket was not large enough to fit the PFE.
b) Access to the PFE located against the west wall of the "drop-in center" was obstructed by a table used for coffee and snacks.
c) The PFE located outside of room 49 was mounted with the top of the PFE handle measured at 61 1/4 inches above the finished floor.
d) The PFE located in the "multi-purpose room" was mounted with the top of the PFE handle measured at 61 1/4 inches above the finished floor.
e) The PFE located outside of room 8 was mounted with the top of the PFE handle measured at 61 1/4 inches above the finished floor.
f) The PFE located by the entrance to the Occupational Therapy room was mounted with the top of the PFE handle measured at 63 inches above the finished floor.

All observations were made in the presence of the Maintenance Assistants and acknowledged by the Director of Quality Assurance and Performance Improvement (QAPI) during the exit conference.

Based on observation, the hospital failed to ensure that corridor doors were maintained free from impediments to closure.

Findings include:

On 08/25/2020 through 08/27/2020, observation revealed the facility failed to ensure that all corridor doors were free from impediments to closure. The following deficiencies were isolated to the Rawson Neal Complex:

a) Room (Rm) B144 - The office suite door leading to the corridor was held open by a plastic wedge.
b) Rm F101 - The corridor door was held open by a plastic wedge.
c) Rm H170 - The corridor door was held open by a plastic wedge.

All observations were made in the presence of the Maintenance Assistants and acknowledged by the Director of Quality Assurance and Performance Improvement (QAPI) during the exit conference.

Based on observation, measurement, and interview, the hospital failed to ensure that walls constructed as smoke and fire barriers were sealed at each point of penetration.

Findings include:

1) On 08/25/2020 through 08/27/2020, observation and measurement revealed unsealed penetrations in the following locations:

A) Rawson Neal Complex
i) Unit C, Southwest Entrance - an approximate 12 inch x 12 inch penetration was cut into the fire barrier in the interstitial space above the double doors at the unit entrance. Two 1 inch unsealed penetrations and an approximately 3 inch x 4 inch penetration were observed in fire barrier, in the interstitial space above the double doors at the unit entrance.
ii) Unit D, South Entrance - an approximate 3 foot x 3 foot penetration was cut into the fire barrier in the interstitial space above the double doors located outside of Room E-169. Per the Maintenance Assistant, the penetrations were made by a contractor that installed a security system on the doors that led into the unit but was unaware that the penetrations were unsealed.
iii) Unit G, East Entrance - A 5 inch unsealed penetration with light coming through it was observed in the fire barrier, in the interstitial space above the double doors at the unit entrance.

B) Dietary Services Building - Electrical Room - An unsealed penetration with light coming through was observed on the north wall above the main 400 Amp Circuit. The penetration was 4 inches in diameter and penetrated the fire barrier located between the electrical room and the kitchen area.

C) Building 3a - Mechanical Room - an unsealed penetration with light coming through was observed on the south wall. The penetration was 1 inch in diameter and penetrated the fire barrier located between the mechanical room and the corridor.

D) Stein Building - Electrical Room - Five conduits above Panel L2B penetrated the hard-lid ceiling. The conduits ranged from approximately 2 inches to 5 inches in diameter and were unsealed between the conduit and the ceiling.

E) Building 1- Information Technology (IT) Room - Five 1 inch conduits and one 4 inch conduit penetrated the interstitial space above the server. The penetrations were unsealed and each conduit appeared to be unprotected internally as light was observed coming through them.

Documentation that illustrated the fire and smoke barrier locations and ratings for each building was requested from the Maintenance Assistant but was not provided prior to completion of the survey.

All observations were made in the presence of the Maintenance Assistants and were acknowledged by the Director of Quality Assurance and Performance Improvement (QAPI) during the exit conference.

Based on observation and measurement, the facility failed to ensure that smoke barrier doors were installed and maintained to resist the passage of smoke.

Findings include:

On 08/25/2020 through 08/27/2020, observation revealed that doors located in smoke barriers were installed and maintained to resist the passage of smoke. The following smoke barrier doors were observed to have a gap between each set of double doors. The gap was measured at 1/2 inch and ran the full distance between each of the doors in the following locations:

1) Rawson Neal Complex - Unit E:
2) Doors located between room E102 and the Nursing Station
3) Doors located between room E103 and the Nursing Station
4) Doors located between rooms E154 and E162
5) Doors located between rooms E163 and E168

All observations and measurements were made in the presence of the Maintenance Assistants. All deficiencies were acknowledged by the Director of Quality Assurance and Performance Improvement (QAPI) during the exit conference.

Based on documentation review, the facility failed to ensure that elevators were inspected and tested as required.

Findings include:

On 08/25/2020, document review revealed the facility did not retain documentation as evidence the elevator located in the Stein building was tested and inspected as required. Additionally the facility failed to maintain a written record that indicated the Firefighter's service was operated monthly. Documentation was requested, but was not provided prior to completion of the survey.

The above deficiency was acknowledged by the Director of Quality Assurance and Performance Improvement (QAPI) during the exit interview.

Based on documentation review, the facility failed to hold fire drills at least quarterly on each shift.

Findings include:

On 08/25/2020, document review revealed the facility failed to conduct fire drills on a quarterly bases. The following buildings and shifts were affected:

1) Rawson Neal Complex:
a) No drills were conducted for day shift (7:00 AM to 7:30 PM) personnel working in unit H between 04/01/2019 and 10/15/2019 (6 months and 14 days)
b) No drills were conducted for night shift personnel (7:00 PM to 7:30 AM) working in units E and G between 01/15/2020 and 07/15/2020 (6 months)

2) Dietary Services Building - No drills were conducted between 08/01/2019 and 8/27/2020 (1 year and 26 days)

3) Dietary Storage Building - No drills were conducted between 08/01/2019 and 08/27/2020 (1 year and 26 days)

4) Building 3a - No drills were conducted between 08/01/2019 and 08/27/2020 (1 year and 26 days)

5) Stein Building:
a) No drills were conducted for night shift personnel (3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM) between 01/27/2020 and 6/16/2020 (5 months and 9 days)
b) No drill was conducted for night shift personnel between 08/01/2019 and 11/10/2019 (3 months and 9 days)

Documentation of the facility's fire drills conducted in building 3a, the dietary services building, and the dietary storage building were requested but were not provided prior to conclusion of the survey.

The above deficiencies were acknowledged by the Director of Quality Assurance and Process Improvement (QAPI) during the exit conference.

Based on document review, observation, and interview the facility failed to 1) adopt smoking regulations that included all required provisions; and 2) failed to make metal containers with self-closing devices readily available into which ashtrays could be emptied in all areas where smoking was allowed.

Findings include:

1) On 08/25/2020, document review revealed the the facility's smoking policy titled "Tobacco and Electronic Cigarette Use," (dated 01/2020) did not include the following required provisions:

a) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
b) Smoking by patients classified as not responsible shall be prohibited

2) On 08/25/2020, observation revealed the facility did not have metal containers readily available with self-closing devices into which ashtrays could be emptied. During an interview, the Maintenance Assistant indicated the facility's metal cans were missing or stolen from each smoking area and had not been replaced.

All observations were made in the presence of the Maintenance Assistants and were acknowledged by the Director of Quality Assurance and Performance Improvement (QAPI) during the exit conference.

National Fire Protection Association (NFPA) 101, Life Safety Code (2012 Edition)
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.
4.6.12.3* Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

19.3.6.5 Openings.
19.3.6.5.1* Miscellaneous openings, such as mail slots, pharmacy pass-through windows, laboratory pass-through windows, and cashier pass-through windows, shall be permitted to be installed in vision panels or doors without special protection, provided that both of the following criteria are met:
(1) The aggregate area of openings per room does not exceed 20 sq. inches (0.015 m2).
(2) The openings are installed at or below half the distance from the floor to the room ceiling.

9.6.3.2.3* Smoke detectors located at doors for the exclusive operation of automatic door release shall not be required to activate the building evacuation alarm, provided that the power supply and installation wiring to the detectors are monitored by the building fire alarm system, and the activation of the detectors initiates a supervisory signal at a constantly attended location.

National Fire Protection Association (NFPA) 80, Fire Doors and Other Opening Protectives (2010 Edition).
5.1.5 Repairs and Field Modifications.
5.1.5.1 Repairs shall be made, and defects that could interfere with operation shall be corrected without delay.
5.1.5.2 Field Modifications.
5.1.5.2.1 In cases where a field modification to a fire door or a fire door assembly is desired, the laboratory with which the product or component being modified is listed shall be contacted and a description of the modifications shall be presented to that laboratory.
5.1.5.2.2 If the laboratory finds that the modifications will not compromise the integrity and fire resistance capabilities of the assembly, the modifications shall be permitted to be authorized by the laboratory without a field visit from the laboratory.

5.2* Inspections.
5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.
5.2.3 Functional Testing
5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

5.2.4 Swinging Doors with Builders Hardware or Fire Door Hardware.
5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.
5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

5.2.13 Prevention of Door Blockage.
5.2.13.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.
5.2.13.2 Where necessary, a barrier shall be built to prevent the piling of material against sliding doors.
5.2.13.3 Blocking or wedging of doors in the open position shall be prohibited.

5.2.14.2 Swinging doors normally held in the open position and equipped with automatic-closing devices shall be operated at frequent intervals to ensure operation.

13.1.2 Types. Service counter fire doors shall be of the following three general types:
(1) Swinging door panels of a single or multiple section vertical type, integrally mounted in a four-sided frame to form a labeled door and frame assembly
(2) Horizontally or vertically sliding door
(3) Rolling steel fire door

13.4 Automatic Closing.
13.4.1 All service counter fire doors shall be equipped to close automatically in the event of fire.
13.4.2 A service counter fire door of the rolling type shall be automatic closing so that, upon activation or release of a fusible link or detector, the door shall close.
13.4.3 A service counter fire door of the swinging or sliding type shall be made automatic closing by a system of weights suspended by ropes, cables, or chains over pulleys that, when activated by release of an automatic fire detector, shall cause the door to close.
13.4.4 A governor, where employed on a service counter fire door, shall work in coordination with the closing device and shall control the closing speed of the door.
13.4.5 A service counter fire door of the rolling type shall have an average closing speed of not less than 6 in./sec (152 mm/sec) or more than 24 in./sec (610 mm/sec).

Based on document review, observation, and interview, the facility failed to ensure that 1) all service counter fire doors were installed in smoke barriers as required, and 2) fire door assemblies were maintained in accordance with NFPA 80.

Findings include:

1) On 08/27/2020, observation and interview revealed the facility failed to ensure that all service counter fire doors were installed as required. The pharmacy service counter, located in unit B of the Rawson Neal Complex, contained two openings each protected by a rolling steel fire door. The openings were located in the smoke barrier and were open to the corridor when the doors were in the open position. The main pharmacy service counter was measured at approximately 105 inches long x 36 inches in height (3780 square inches) and the second pharmacy service counters measured at approximately 48 inches long x 36 inches in height (1728 square inches). Both rolling steel fire doors were installed with the fire rating and inspection tag located inside the guide rails and were not visible on either door. Document review revealed that neither door was documented as inspected and tested on the facility's annual door report dated 7/15/2020.

During an interview, the Maintenance Assistant indicated that the doors were operated by manual controls located on the southeast wall of the pharmacy service counter area. The Maintenance Assistant also indicated the fire doors were not equipped to close upon activation of the fire and smoke detection system.

2) On 08/25//2020 through 08/27/2020, observation revealed the facility failed to ensure that fire door assemblies were continuously maintained in accordance with NFPA 80. Deficiencies were observed on the following fire door assemblies:

A) Dietary Services Building
i) The 1 1/2 hour fire door located between the employee break room and main kitchen area was held open by a plastic wedge.
ii) A dead-bolt locking mechanism was installed on the 1 1/2 hour double fire doors located at the south exit of the main kitchen. During an interview the Executive Chef indicated the dead-bolt was installed to prevent unwanted entry into the building. The Executive Chef and Maintenance Assistants were unable to provide information on the locking mechanism or the date when it was installed.

B) Building 3a
i) The fire door located between the lobby and the entrance to area 30 was repainted and covered the fire door rating label located on the hinge side of the door. This prevented the ability to determine the door's fire rating.
ii) The panic bar on the 1 1/2 hour fire door that was identified by signage as an emergency exit was missing. The door did not have any hardware in place to ensure the door would open and latch properly.

3) On 08/25/2020, document review revealed the facility failed to demonstrate that the individuals that performed the inspection, testing, and maintenance of the facility's smoke and fire doors possessed the requisite knowledge, training, or experience that demonstrated their ability to perform door inspections. The facility provided an annual door report that was dated 07/15/2020 that did not provide any identifying information to determine the person who performed the annual inspection or that the person possessed the requisite knowledge, training, or experience to perform the annual door inspections.

All observations were made in the presence of the Maintenance Assistants and were acknowledged by the Director of Quality Assurance and Performance Improvement (QAPI) during the exit conference.

Based on observation and interview, the hospital failed to ensure that portable space-heating devices that were located in nonsleeping staff and employee areas were fitted with heating elements that did not exceed 212 degrees Fahrenheit (100 degrees Celsius).

Findings include:

During the facility tours on 08/25/2020 through 08/27/2020, observation revealed that staff were utilizing portable space-heating devices, without a label or documentation that verified the device's heating element did not exceed 212 degrees Fahrenheit (100 degrees Celsius), in the following locations within the Rawson Neal Complex:

1) Room (Rm) C179 - Patient Advocate Office
2) Rm C142 - Social Worker Office
3) Rm F128 - Social Worker Office
4) Rm F170 - Physician's Office
5) Rm B171 - Pharmacy Office

All observations were made in the presence of the Maintenance Assistants and were acknowledged by the Director of Quality Assurance and Performance Improvement (QAPI) during the exit conference.

Based on observation and interview, the facility failed to ensure that 1) Non-hospital grade electrical receptacles were tested at intervals not exceeding 12 months; and 2) hospital-grade receptacles were tested after initial installation, replacement, or servicing and at intervals defined by documented performance data.

Findings include:

1) On 07/29/2020, document review revealed the hospital did not perform annual testing on all non-hospital grade electrical receptacles located throughout the facility. Documentation of annual testing on all non-hospital grade receptacles was requested, but was not provided prior to completion of the survey..

2) On 7/29/2020, document review revealed the hospital did not perform testing on hospital grade receptacles upon installation, replacement or servicing nor did the hospital obtain performance data to define the intervals for testing of the facility's hospital-grade receptacles. Documentation of testing on all hospital-grade receptacles was requested, but was not provided prior to completion of the survey.

The above deficiencies were acknowledged during the exit conference.

Based on observation and interview, the facility failed to ensure that a hard-wired remote annunciator with battery-powered backup was installed outside of the generator enclosures and in a room readily observed by operating personnel.

Findings include:

On 08/25/2020, observation revealed the facility failed to install remote annunciators that operated outside of the generator enclosure and were observed by operating personnel. During an interview, the Maintenance Assistant indicated the facility did not have remote annunciators for the facility's main generator and the generators that serviced the dietary services building and building 3a.

All observations were made in the presence of the Maintenance Assistants and were acknowledged during the exit conference.

National Fire Prevention Association (NFPA) 110, Standard for Emergency and Standby Power Systems (2010 Edition)
5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

7.11 Protection.
7.11.1 The room in which the EPS equipment is located shall not be used for other purposes that are not directly related to the EPS. Parts, tools, and manuals for routine maintenance and repair shall be permitted to be stored in the EPS room.

8.2* Manuals, Special Tools, and Spare Parts.
8.2.1 At least two sets of instruction manuals for all major components of the EPSS shall be supplied by the manufacturer(s) of the EPSS and shall contain the following:
(1) A detailed explanation of the operation of the system
(2) Instructions for routine maintenance
(3) Detailed instructions for repair of the EPS and other major components of the EPSS
(4) An illustrated parts list and part numbers
(5) Illustrated and schematic drawings of electrical wiring systems, including operating and safety devices, control panels, instrumentation, and annunciators

8.3.2.1 The operational test shall be initiated at an ATS and shall include testing of each EPSS component on which maintenance or repair has been performed, including the transfer of each automatic and manual transfer switch to the alternate power source, for a period of not less than 30 minutes under operating temperature.

8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.
8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer

8.4 Operational Inspection and Testing
8.4.1* EPSSs, including all appurtenant components shall be inspected weekly and exercised under load at least monthly.
8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating.

Based on document review, observation, and interview, the facility failed to ensure that 1) all generators had a remote manual stop station installed outside of the generator enclosures or elsewhere on the premises; 2) all generator sets were inspected weekly; 3) diesel-powered generator sets were exercised at least monthly, for a minimum of 30 minutes under loading that maintains the minimum exhaust temperatures as recommended by the manufacturer or under operating conditions not less than 30 percent of the EPS nameplate and kW rating; 4) annual 1 1/2 hour load bank testing was performed on all diesel-powered generator sets and; 5) maintain two sets of instruction manuals for each generator set.

Findings include:

1) During the facility tours conducted 08/25/2020 through 08/27/2020, observation revealed the facility did not have remote manual stop stations installed outside of the generator enclosures or elsewhere on the premises in the following locations:

a) Generator #1 - Diesel-powered, 1800 kW located next to building F. The remote stop station was installed inside of the generator enclosure.
b) Generator #2 - Natural gas-powered, 60 kW located next to the dietary services building. The remote stop was installed on the outside of the generator casing.
c) Generator #3 - Diesel-powered, 1020 kW located next to building 3a. The remote stop station was installed inside of the generator enclosure.

During an interview, the Maintenance Assistant indicated that the generator enclosures remain locked at all times with maintenance personnel holding the keys for entry.

2) On 08/25/2020, document review revealed the facility failed to perform weekly inspections on all generator sets as required. The facility provided a document entitled "Emergency Generator Inspection Services" that was dated 11/19/2017. The document included a list of 12 line items to be included on the weekly inspection, however, the line items appeared with one "check mark" next to each item. A separate piece of paper was attached to the document that contained dates and a "check mark" that indicated the main generator was inspected on a weekly basis between 11/21/17 and 03/30/2020. At the time of the survey, the main generator was overdue for weekly inspection by 4 months and 22 days. Documentation of the weekly inspections that were performed on generators #2 and #3 were requested but were not provided prior to completion of the survey.

3) Document review revealed the facility failed to exercise each generator set for 30 minutes, 12 times a year, in 20-40 day intervals. The provided a document titled "Emergency Generator Inspection Services" that was dated 11/19/2017. A list of dates were identified by a circle and a statement that said "30 min," however there was no indication that the main diesel-powered generator set was exercised for at least 30 minutes at the manufacturer recommended operating temperature or at least 30 percent of the generator's nameplate and kW rating. Documentation as evidence that generator sets #2 and #3 were exercised for at least 30 minutes, 12 times a year, at 20-40 day intervals was requested but was not provided prior to completion of the survey.

4) Document review revealed the facility failed to complete annual 1 1/2 hour load bank testing on each diesel-powered generator as required. The facility provided a copy of a letter from a vendor that indicated generator #3 was exercised under 100 percent load on 03/28/2019, however this document did not include identification of the servicing personnel; notation of unsatisfactory conditions; or indication of the length of time that the generator was exercised. Documentation as evidence that a 1 1/2 hour load bank test was performed on generators #1 and #3 (diesel-powered generators) was requested but was not provided prior to completion of the survey.

5) On 08/25/2020, two sets of instruction manuals for each generator set was requested from the Maintenance Assistant. During an interview, the Maintenance Assistant indicated that he was unable to determine the location of the generator instruction manuals. Evidence that the facility maintained two sets of instruction manuals for each generator was not provided prior to completion of the survey.

All observations were made in the presence of the Maintenance Assistants and were acknowledged during the exit conference.

National Fire Protection Association (NFPA) 70, National Electric Code, (2011 Edition)

EXTENSION CORDS
Article 590.2 All Wiring Installations.
Article 590.2(A) Other Articles. Except as specifically modified in this article, all other requirements of this Code, for permanent wiring shall apply to temporary wiring installations.
Article 400.8 Uses Not Permitted. Unless specifically permitted in Article 400.7, flex cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure.
(2) Where run through holes in walls, structural ceilings, suspended ceiling, dropped ceilings or floors.
(3) Where run through doorways, windows or similar openings.
(4) Where attached to building surfaces.
exception to (4): Flex cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56.
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings.
(6) Where installed in raceways, except as otherwise permitted by the Code.
(7) Where subject to physical damage.

CLEARANCES
(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26 (A)(1) unless the requirements of 110.26 (A)(1)(a), (A)(1)(b), or (A)(1)(c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed. (Nominal Voltage to Ground of 0 -150 = 3 feet).

COVERS
Article 314 - Outlet, Device, Pull, and Junction Boxes; Conduit bodies; Fittings; and Handhole Enclosures
314.25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, lampholder, or luminaire canopy, except where the installation complies with 410.24(B).
314.28(c) Pull and Junction Boxes and Conduit Bodies.
(c) Covers. 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 used, metal covers shall comply with the grounding requirements of 250.110.

Article 408.4 Field Identification Required.
(a) Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy.

Based on observation and interview, the facility failed to ensure that the building's electrical system was maintained and repaired in accordance with NFPA 70.

Findings include:

The following findings were observed during the facility tours conducted on 08/25/2020 through 08/27/2020:

1) The facility was using relocatable power taps (RPTs) and extension cords throughout the Rawson Neal Complex and Building. The following locations were the most salient examples of the use of extension cords, RPTs, and multipliers as a substitute for permanent wiring and/or in an unsafe manner as described below:

A) Rawson Neal Complex:
i) Room (Rm) C151 - An eight-plug RPT was used to power a refrigerator, microwave, and a coffee maker.
ii) Rm C142 - An eight-plug RPT was used to power a portable space-heating device.
iii) Rm C130 - A six-plug RPT was used to power a microwave.
iv) Rm F127 - A six-plug RPT was used to power a microwave and a refrigerator.
v) Rm F159 - An eight-plug RPT used to power a refrigerator and microwave was plugged into another eight-plug RPT that was used to power a coffee maker and was plugged into a wall receptacle (daisy chained).
vi) Rm H126 - A six-plug RPT was used to power a refrigerator and a microwave.
vii) Rm H128 - A six-plug RPT was used to power a microwave.
viii) Rm H158 - A six-plug RPT was used to power a microwave and a coffee maker.
ix) Rm A109 - A six-plug RPT was used to power a microwave. The six-plug RPT was connected to an orange extension cord that was plugged into a wall receptacle (daisy chained).
x) Rm B120 - A six-plug RPT was used to power a coffee maker.
xi) Pharmacy - A six-plug RPT was used to power a pill counting machine.
xii) Rm B177 - A six-plug RPT was used to power a microwave and a refrigerator.
xiii) Rm B171 - A six-plug RPT was used to power a coffee maker and a refrigerator.

A) Building 1:
i) Drop-in Center - A four-plug RPT was used to power two coffee makers.
ii) Rm 47 - A six-plug RPT was used to power a portable space-heating device.
iii) Rm 45 - A six-plug RPT was used to power a microwave.
iv) Conference Room - A four-plug RPT (without a UL listing) was plugged into an 8-plug RPT that was used to power two televisions and was plugged into an 11-plug RPT that was plugged into a wall receptacle (daisy chained).
v) Rm 41 - A six-plug RPT was used to power a microwave. A separate six-plug RPT was used to power a portable space-heating device.
vi) Rm 39 - A six-plug RPT was used to power a portable space-heating device.
vii) Rm 34b - A six-plug RPT used to power office equipment was connected to an 11-plug RPT that was plugged into a wall receptacle (daisy chained). A separate eight-plug RPT was used to power a refrigerator and a microwave.
viii) Rm 19c - An eight-plug RPT was used to power a refrigerator.
ix) Rm 13 - An eight-plug RPT used to power office equipment was plugged into a three-plug RPT that was plugged into a wall receptacle (daisy chained).
x) Rm 69b - Two eight-plug RPTs used to power office equipment were plugged into a six-plug RPT that was plugged into a wall receptacle (daisy chained).
xi) Medical Records (Back office) - A six-plug RPT was used to power a coffee maker and a portable space-heating device.

2) The facility failed to maintain and/or repair electrical outlets, pull boxes, junction boxes, and conduit bodies throughout the facility. The following deficiencies were observed on the facility tours conducted 08/25/2020 through 08/27/2020:

A) Rawson Neal Complex:
i) An open junction box was observed in the interstitial space above the smoke barrier doors at the north entrance to unit E.
ii) An open junction box was observed in the interstitial space above the smoke barrier doors at the southwest entrance to unit C.
iii) An open junction box was observed in the interstitial space above the smoke barrier doors at the southwest entrance to unit D.

B) Dietary Services Building:
i) The ground contact on the Ground-Fault Circuit Interrupter (GFCI) outlet above the preparation area located to the left of the refrigerator was broken.
ii) The ground contact on the GFCI above preparation area located to the right of the refrigerator was broken.

C) Dietary Storage Building - open junction box was observed in the archive room.

D) Building 3a
i) Rm 6 - The ground contact on one of the wall receptacles was broken.
ii) Rm 11 - The ground contact on one of the wall receptacles was broken.
iii) Rm 10a - The ground contact on one of the wall receptacles was broken.
iv) Rm 16 - A 1/4 inch gap was observed between the wall receptacle coverplate and the outlet box.
v) Rm 27 - The outlet cover on the wall receptacle labeled "BB1-25" was broken. A 1/4 inch gap was observed between the wall receptacle cover plate labeled "BB1-23" and the outlet box.
vi) Security Alcove - The junction box located in this area was missing a cover.

E) Stein Building - Machinery Room - An uncovered electrical box on the installed fluorescent light exposed unprotected electrical wiring.

F) Building 1:
i) Conference Room - The junction box located near the television sets was missing a cover. The ground contact on one outlet installed on the west wall and two outlets on the east wall were broken.
ii) Medication Room - The telephone junction box was uncovered and exposed unprotected wiring.
iii) Group Therapy Room - The junction box located above the television was missing a cover.
iv) Corridor - The ground contact on the outlets across from Rm 54 were broken.
v) Rm 59 - The telephone junction box was uncovered and exposed unprotected wiring.
vi) Rm 69 - The electrical outlet was retracted from the wall and created a 1/2 inch gap between the wall and the outlet box.

3) Based on observation, the facility failed to ensure that a distance of three feet was maintained between exposed live electrical parts or from the enclosure or opening if the live parts are enclosed in the following areas:

A) Rawson Neal Complex:
i) Electrical Room, C unit - Enamel-based paint was stored directly in front of panels L6 and L7. Conduit, pipes, and paper waste was stored directly in front of panel H4.
ii) Chiller Room, F unit - Two large boxes and a nitrogen tank were stored in front of switch MCC-1. A box and two shopping carts with maintenance supplies were stored in front of the Auxiliary Battery Supply (ABS) batteries.
iii) Boiler Room, F unit - A ladder was leaning on switch MCC-2. An air compressor was stored in front of the ABS batteries.
iv) Electrical Room, F unit - Maintenance carts were stored in front of panels K1, L1, and H1.
v) Rm B175 - Cardboard and a ladder were stored in front of panels L9, L8, and H5.

B) Dietary Services Building:
i) Kitchen - Dry storage boxes were stored in front of panel KA1 and switch MAV1.
ii) Electrical Room - One bag of salt pellets was stored leaning against the main 400 AMP circuit.

C) Dietary Storage Building:
i) Electrical Room - Two food warming carts with hoses were stored in front of panel E.
ii) North Courtyard/Storage Area - A wooden park bench was placed in front of panel D.

D) Stein Building - Boiler Room - Two ladders were stored against panel L1A.

E) Building 1:
i) Machinery Room - A ladder was stored leaning against panels AH and AA.
ii) Rm 8 - The facility installed wooden storage shelves directly under panel AF.

4) Based on observation, the facility failed to ensure that every circuit and circuit modification was legibly identified to its clear, evident, and specific purpose and included sufficient detail to allow each circuit to be distinguished from all others. The following electrical panels and switches were identified with deficient circuit identification:

A) Rawson Neal Complex:
i) Riser Room A - L11
ii) Riser Room A - L10

B) Dietary Services Building - KB

C) Building 3a
i) Electrical Room - BB1
ii) Electrical Room - BB2

D) Stein Building
i) Electrical Room - L2B
ii) Boiler Room - L1A
iii) Boiler Room - H1A

E) Building 1
i) Machinery Room - AH
ii) Machinery Room - AA
iii) Rm 39 - AL
iv) Rm 8 - AF

All observations were made in the presence of the Maintenance Assistants. All deficiencies were acknowledged by the Director of Quality Assurance and Performance Improvement (QAPI) during the exit conference.