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Based on observation and staff interview the facility failed to provide smoke resistant partitions in accordance with NFPA 101. The findings were:

Observation on 09/15/2016 at 9:27 AM located in the Maintenance Office revealed that the door frame was not resistant to the passage of smoke. Further observation revealed that the office door was connected to the corridor and that the caulking was missing from the door frame and therefore light was exposed from the corridor into the maintenance room through the gap. Interview with the Facility Maintenance Manager at the time of observation acknowledged the gap in door frame.

Ref:
2000 NFPA 101, Section 19.3.6.2.2

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Based on observation and staff interview, the facility failed to ensure hazardous areas were protected from the corridor with self-closing doors. The findings were:

1. Observation on 09/13/2016 at 9:50 AM located at the Respitory Therapy Storage revealed a storage room that was not equipped with a self-closing device. Further observation revealed that the room was greater than 50 square feet and contained combustible material. Interview with the Facility Maintenance Staff at the time of observation acknowledged the door was not self-closing.

2. Observation on 09/15/2016 at 9:13 AM located in the Storage Room across from Material Handling Room revealed the room was not equipped with a self-closing device. Further observation revealed that the room was greater than 50 square feet and contained combustible material. Interview with the Facility Maintenance Staff at the time of observation acknowledged the door was not self-closing.

3. Observation on 09/13/2016 at 2:42 PM located at the ER storage revealed the room was not equipped with a self-closing device. Further observation revealed that the room was greater than 50 square feet and contained combustible material. Interview with the Facility Maintenance Staff at the time of observation acknowledged the door was not self-closing.

2000 NFPA 101, Section 19.3.2.1

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Based on observation and staff interview, the facility failed to ensure hazardous areas were protected from the corridor with self-closing doors. The findings were:

Observation on 09/15/2016 at 11:22 AM located at the auxiliary medical clinic Hall C revealed that the clean linen storage room was propped open to the corridor with a bag of linen. Interview with the Facility Maintenance Manager at the time of observation acknowledged that the hazardous room was propped open to the corridor.

Ref:
2000 NFPA 101, Section 38.3.2

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Based on observation and staff interview, the facility failed to arrange exits that are readily accessible at all times in accordance with NFPA 101. The findings were:

1. Observation on 09/13/2016 at 12:40 PM revealed a delayed egress door without the proper signage indicating the use of the delayed egress locking system located on the third floor North West exit stairwell door. Interview with the Facility Maintenance Manager at the time of observation was unaware of this requirement

2. Observation on 09/13/2016 at 12:57 PM revealed a delayed egress door without the proper signage indicating the use of the delayed egress locking system located on the third floor adjacent to room 312 North East exit stairwell door. Interview with the Facility Maintenance Manager at the time of observation was unaware of this requirement.

3. Observation on 09/13/2016 at 1:10 PM located at door 312 revealed a pad lock that was only able to be unlocked from the corridor with a key. Further observation revealed that only maintenance had a key to the pad lock and that the room was only being utilized as storage. Interview with the facility maintenance manager at the time of observation acknowledged the pad lock was only operable from the corridor side and that the maintenance staff only had the key.

Ref:
2000 NFPA 101, Sections 19.2.1 And 7.2.1.6.1

4. Observation on 09/13/2016 at 2:05 PM located on the 2nd floor OR corridor revealed a North exit door that had a deadbolt. Further observation revealed that the deadbolt could be locked from the other side of the door and also no staff besides maintenance had a key. Facility Maintenance Manager at the time of observation acknowledge the dead bolt on the exit door.

Ref:
2000 NFPA 101, Section 19.2.2.2.4

5. Observation on 09/13/2016 at 4:03 PM located at the Orthopedic exit to the outside revealed two ramps to the public way that had a rise greater than 6 inches. Further observation reveled that there were no handrails for either ramp. Interview with the Facility Maintenance Manager at the time of observation was unaware that each ramp with a rise greater than 6 inches requires a handrail on each side of the ramp.

Ref:
2000 NFPA 101, Sections 19.2.1 and 7.2.5

6. Observation on 09/15/2016 at 11:28 AM located at the auxiliary medical clinic revealed a North East and North exit that had obstructions in the means of egress. The North East exit vestibule had a desk that impeded upon egress and the North exit had approximately (13) Culigan water refills impeding egress.

Ref:
2000 NFPA 101, 7.1.3.2.3

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Based on observation and staff interview, the facility failed to provide exit and directional signs in accordance with NFPA 101. The findings were:

1. Observation on 09/13/2016 at 1:55 PM revealed a missing exit sign to show means of egress passage from the imaging corridor to the elevator lobby and a missing exit sign to show means of egress passage from the imaging corridor to the ER waiting area. Interview with the Facility Maintenance Manager at the time of observation acknowledged the missing exit signs.

2. Observation on 09/15/2016 at 8:20 AM located adjacent to OR # 1 revealed an exit door with an illuminated exit sign above the door and further observation revealed another sign posted on the door that read "STOP NOT AN EXIT". Interview with the Facility Maintenance Manager at the time of reservation acknowledged that the exit signs were not in accordance with NFPA 101.

Ref:
2000 NFPA 101, Sections 19.2.10.1 and 7.10

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Based on document review and staff interview the facility failed to perform fire drills in accordance to NFPA 101. The findings were:

Document review on 09/15/2016 at 10:45 revealed that the facility was missing fire drills for the first quarter of 2016 on each shift. Further review revealed a fire drill missing for one shift in the 2nd quarter of 2016 and the fourth quarter of 2015. Interview with the Facility Maintenance Manager at the time of review acknowledged the missing fire drills.

Ref:
2000 NFPA 101, 19.7.1.2

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Based on document review, observation, and staff interview, the facility failed to ensure that the fire alarm system was tested and maintained per the requirements of NFPA 72. The findings were:

1. Observation and document review on 09/13/2016 at 2:55 PM revealed the central station fire alarm system UL certificate was not posted at the annunciator panel. Interview with the Facility Maintenance Manager at the time of the review acknowledged the certificate was missing.

Ref:
2000 NFPA 101, Sections 19.3.4.1 and 9.6.1.4
1999 NFPA 72, Section 1-6.2.3.1.1

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Based on document review and staff interview the facility failed to maintain the automatic sprinkler system in accordance with NFPA 25. The findings were:

Document review on 09/15/2016 at 10:20 AM revealed that the facility failed to test the preaction sprinkler system in the IT/Sever room for the required annual test. Further observation revealed that the documents only showed a visual inspection and indicated that a test could not be run at that time. Interview with the Facility Maintenance Manager at the time of review said that the test could not be preformed due to an IT update. Further interview with the Facility maintenance Manager acknowledged the missing annual test.

Ref:
2000 NFPA 101, Section 19.3.5

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Based on observation and staff interview the facility failed to ensure that the automatic sprinkler systems are installed, and continuously maintained per the requirements of NFPA 13 and 25. The findings were:

1. Observation on 09/13/2016 at 2:30 PM of the X-ray Flouro room and at 4:00 PM of the Orthopedic x-ray room revealed sprinkler heads that were obstructed by x-ray machine equipment. Interview with the Facility Maintenance Manager at the time of the observation acknowledged that the x-ray equipment obstructed the sprinkler heads.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.5
1998 NFPA 25, Section 2-2.1.1

2. Observation of the sprinkler riser room on 09/13/2016 at 2:55 PM revealed the fire riser had been modified from the original installation for the addition of a reduced pressure principle backflow preventer and valves. No hydraulic calculations were posted. Interview with the Facility Maintenance Manager at the time of observation was unaware the hydraulic calculations were missing.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.1.1
1999 NFPA 13, Sections 5-515.4.6.2 and 10-5

3. Observation on 09/15/2016 at 8:52 AM located in the IT/Sever Room revealed 3 ceiling tiles that were missing. Further observation revealed that the sprinkler heads were adjacent to the missing tiles. Interview with the Facility Maintenance Manager at the time of observation acknowledged that the missing ceiling tile would delay the sprinkler heads.

Ref:
2000 NFPA 101, Sections 19.3.5.1, 9.7.1.1, and 9.7.5
1999 NFPA 13, Section 5-6.4.1.1
1998 NFPA 25, Sections 2-2.1.1 and 2-2.7

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Based on observation and staff interview, the facility failed to ensure that the automatic sprinkler systems are installed, and continuously maintained per the requirements of NFPA 13. The findings were:

1. Observation on 09/13/2016 from 10:35 AM to 11:05 AM located on the fourth floor in the IT department adjacent to the bathroom, Business Office Corridor adjacent to room 4310, Business Office Corridor adjacent to Exit door, and throughout the 4th floor area revealed that there were sprinkler heads that were recessed into the ceiling tiles obstructing sprinkler discharge. Interview with the Facility Maintenance Manager at the time of observation acknowledged that the sprinkler heads were obstructed.

2. Observation on 09/13/2016 at 10:56 AM located on the fourth floor in the Environmental Storage Room revealed a sprinkler escutcheon that was missing. Interview with the Facility Maintenance Manager at the time of observation acknowledged that the sprinkler escutcheon was missing.

3. Observation on 09/15/2016 at 11:22 AM located at the auxiliary medical clinic adjacent to Hall D revealed a storage room that had a sprinkler head obstructed. Further observation revealed that there were boxes within 5 inches of the ceiling. Interview with the Facility Maintenance Manager acknowledged that the boxes were obstructing the sprinkler head.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.5
1999 NFPA 13, Section 5-5.5.2

4. Observation on 09/15/2016 at 11:20 AM located at the auxiliary medical clinic revealed two outside overhangs exceeding 4 ft in width at the North East and North exits. Further observation revealed that the assembly for the overhangs were made from combustible material and were not provided with sprinkler protection. Interview with Facility Maintenance Manager at the time of observation stated the building was fully sprinkled.

Ref:
1999 NFPA 12, Section 5-13.8

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Based on observation and staff interview, the facility failed to provide portable fire extinguishers in accordance with NFPA 10. The findings were:
Observation on 09/13/2016 at 3:50 PM located on the 2nd floor receptionist area revealed a fire extinguisher that was not mounted to the wall and sitting on the cabinet. Interview with the Facility Maintenance Manager at the time of observation acknowledged that the extinguisher was not mounted.
Ref:
2000 NFPA 101, Sections 19.3.5.6 and 9.7.4.1
1998 NFPA 10, Section 1-6.10

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Based on observation and staff interview, the facility failed to provide oxygen storage location in accordance with NFPA 99. The findings were:

Observation on 09/15/2016 at 9:02 AM located at the outside oxygen storage tank revealed a receptacle that was lower than 60 inches from the ground. Interview with the Facility Maintenance Manager at the time of observation was unaware of the requirements.

Ref:
1999 NFPA 99, Section 4-3.1.1.2 (4)

Observation on 09/15/2016 at 9:02 AM located at the outside oxygen storage tank revealed combustible/flammable materials located within the fencing adjacent to oxygen tanks. Interview with the Facility Maintenance Manager at the time of observation acknowledged there were cardboard boxes that were stuck in the fence.

Ref:
1999 NFPA 99, Section 4-3.1.1.2 (7)

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Based on observation and staff interview the facility failed to provide an emergency shower in accordance with NFPA 99. The findings were:

Observation on 09/13/2016 at 2:15 PM located in the laboratory revealed that the facility failed to provide the lab with and emergency shower. Interview with the Facility Maintenance Manager acknowledge they were unaware of the requirement.

Ref:
1999 NFPA 99 Section 10.6

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Based on document review and staff interview the facility failed to routinely test the generators in accordance with NFPA 110. The findings were:

Document review on 09/15/2016 at 10:42 AM revealed that the facility was doing monthly generator tests, but failed to provide a KW rating of at least 30% of the name plate rating and/or providing the minimum exhaust gas temperature as recommended by the manufacturer. Interview with the Facility Maintenance Manager at the time of review acknowledged they were unaware of the requirements.

Ref:
2000 NFPA 101, Sections 19.5.1 and 9.1.3
1999 NFPA 110, Sections 6-4.2 and 6-4.2.2

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Based on observation and staff interview the facility failed to demonstrate emergency powered lighting at the generator in accordance with NFPA 99. The findings were:

Observation on 09/15/2016 at 10:00 AM located at the outside generator revealed that the facility did not have emergency battery powered lighting unit(s). Interview with the Facility Maintenance Manager at the time of observation acknowledged that the facility did not have emergency battery powered lighting for their generator.

Ref:
1999 NFPA 99, Section 3-4.2.2.2 (b)5

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Based on observation and staff interview, the facility failed to meet electrical wiring in accordance with NFPA 70. The findings were:
1. Observation on 09/13/2016 at 1:20 PM located in the staff break room 330 and at 1:25 PM located at the women's locker on the 3rd floor revealed receptacles approximately 2 feet away from sinks that were not equipped with a ground-fault circuit-interrupters. Interview with the Facility Maintenance Manager at the time of observation acknowledged the missing ground-fault circuit-interrupters.
Ref:
1999 NFPA 70, Article 210.8

2. Observation on 09/13/2016 at 2:00 PM located in the Laboratory revealed a receptacle with a missing face place adjacent to the refrigerator. Interview with the Facility Maintenance Manager at the time of observation acknowledged the missing face plate.

Ref:
2000 NFPA 101, Sections 19.5.1 and 9.1.2
1999 NFPA 70, Article 370-25

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Based on observation and staff interview the facility failed to provide smoke resistant partitions in accordance with NFPA 101. The findings were:

Observation on 09/15/2016 at 9:27 AM located in the Maintenance Office revealed that the door frame was not resistant to the passage of smoke. Further observation revealed that the office door was connected to the corridor and that the caulking was missing from the door frame and therefore light was exposed from the corridor into the maintenance room through the gap. Interview with the Facility Maintenance Manager at the time of observation acknowledged the gap in door frame.

Ref:
2000 NFPA 101, Section 19.3.6.2.2

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Based on observation and staff interview, the facility failed to ensure hazardous areas were protected from the corridor with self-closing doors. The findings were:

1. Observation on 09/13/2016 at 9:50 AM located at the Respitory Therapy Storage revealed a storage room that was not equipped with a self-closing device. Further observation revealed that the room was greater than 50 square feet and contained combustible material. Interview with the Facility Maintenance Staff at the time of observation acknowledged the door was not self-closing.

2. Observation on 09/15/2016 at 9:13 AM located in the Storage Room across from Material Handling Room revealed the room was not equipped with a self-closing device. Further observation revealed that the room was greater than 50 square feet and contained combustible material. Interview with the Facility Maintenance Staff at the time of observation acknowledged the door was not self-closing.

3. Observation on 09/13/2016 at 2:42 PM located at the ER storage revealed the room was not equipped with a self-closing device. Further observation revealed that the room was greater than 50 square feet and contained combustible material. Interview with the Facility Maintenance Staff at the time of observation acknowledged the door was not self-closing.

2000 NFPA 101, Section 19.3.2.1

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Based on observation and staff interview, the facility failed to ensure hazardous areas were protected from the corridor with self-closing doors. The findings were:

Observation on 09/15/2016 at 11:22 AM located at the auxiliary medical clinic Hall C revealed that the clean linen storage room was propped open to the corridor with a bag of linen. Interview with the Facility Maintenance Manager at the time of observation acknowledged that the hazardous room was propped open to the corridor.

Ref:
2000 NFPA 101, Section 38.3.2

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Based on observation and staff interview, the facility failed to arrange exits that are readily accessible at all times in accordance with NFPA 101. The findings were:

1. Observation on 09/13/2016 at 12:40 PM revealed a delayed egress door without the proper signage indicating the use of the delayed egress locking system located on the third floor North West exit stairwell door. Interview with the Facility Maintenance Manager at the time of observation was unaware of this requirement

2. Observation on 09/13/2016 at 12:57 PM revealed a delayed egress door without the proper signage indicating the use of the delayed egress locking system located on the third floor adjacent to room 312 North East exit stairwell door. Interview with the Facility Maintenance Manager at the time of observation was unaware of this requirement.

3. Observation on 09/13/2016 at 1:10 PM located at door 312 revealed a pad lock that was only able to be unlocked from the corridor with a key. Further observation revealed that only maintenance had a key to the pad lock and that the room was only being utilized as storage. Interview with the facility maintenance manager at the time of observation acknowledged the pad lock was only operable from the corridor side and that the maintenance staff only had the key.

Ref:
2000 NFPA 101, Sections 19.2.1 And 7.2.1.6.1

4. Observation on 09/13/2016 at 2:05 PM located on the 2nd floor OR corridor revealed a North exit door that had a deadbolt. Further observation revealed that the deadbolt could be locked from the other side of the door and also no staff besides maintenance had a key. Facility Maintenance Manager at the time of observation acknowledge the dead bolt on the exit door.

Ref:
2000 NFPA 101, Section 19.2.2.2.4

5. Observation on 09/13/2016 at 4:03 PM located at the Orthopedic exit to the outside revealed two ramps to the public way that had a rise greater than 6 inches. Further observation reveled that there were no handrails for either ramp. Interview with the Facility Maintenance Manager at the time of observation was unaware that each ramp with a rise greater than 6 inches requires a handrail on each side of the ramp.

Ref:
2000 NFPA 101, Sections 19.2.1 and 7.2.5

6. Observation on 09/15/2016 at 11:28 AM located at the auxiliary medical clinic revealed a North East and North exit that had obstructions in the means of egress. The North East exit vestibule had a desk that impeded upon egress and the North exit had approximately (13) Culigan water refills impeding egress.

Ref:
2000 NFPA 101, 7.1.3.2.3

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Based on observation and staff interview, the facility failed to provide exit and directional signs in accordance with NFPA 101. The findings were:

1. Observation on 09/13/2016 at 1:55 PM revealed a missing exit sign to show means of egress passage from the imaging corridor to the elevator lobby and a missing exit sign to show means of egress passage from the imaging corridor to the ER waiting area. Interview with the Facility Maintenance Manager at the time of observation acknowledged the missing exit signs.

2. Observation on 09/15/2016 at 8:20 AM located adjacent to OR # 1 revealed an exit door with an illuminated exit sign above the door and further observation revealed another sign posted on the door that read "STOP NOT AN EXIT". Interview with the Facility Maintenance Manager at the time of reservation acknowledged that the exit signs were not in accordance with NFPA 101.

Ref:
2000 NFPA 101, Sections 19.2.10.1 and 7.10

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Based on document review and staff interview the facility failed to perform fire drills in accordance to NFPA 101. The findings were:

Document review on 09/15/2016 at 10:45 revealed that the facility was missing fire drills for the first quarter of 2016 on each shift. Further review revealed a fire drill missing for one shift in the 2nd quarter of 2016 and the fourth quarter of 2015. Interview with the Facility Maintenance Manager at the time of review acknowledged the missing fire drills.

Ref:
2000 NFPA 101, 19.7.1.2

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Based on document review, observation, and staff interview, the facility failed to ensure that the fire alarm system was tested and maintained per the requirements of NFPA 72. The findings were:

1. Observation and document review on 09/13/2016 at 2:55 PM revealed the central station fire alarm system UL certificate was not posted at the annunciator panel. Interview with the Facility Maintenance Manager at the time of the review acknowledged the certificate was missing.

Ref:
2000 NFPA 101, Sections 19.3.4.1 and 9.6.1.4
1999 NFPA 72, Section 1-6.2.3.1.1

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Based on document review and staff interview the facility failed to maintain the automatic sprinkler system in accordance with NFPA 25. The findings were:

Document review on 09/15/2016 at 10:20 AM revealed that the facility failed to test the preaction sprinkler system in the IT/Sever room for the required annual test. Further observation revealed that the documents only showed a visual inspection and indicated that a test could not be run at that time. Interview with the Facility Maintenance Manager at the time of review said that the test could not be preformed due to an IT update. Further interview with the Facility maintenance Manager acknowledged the missing annual test.

Ref:
2000 NFPA 101, Section 19.3.5

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Based on observation and staff interview the facility failed to ensure that the automatic sprinkler systems are installed, and continuously maintained per the requirements of NFPA 13 and 25. The findings were:

1. Observation on 09/13/2016 at 2:30 PM of the X-ray Flouro room and at 4:00 PM of the Orthopedic x-ray room revealed sprinkler heads that were obstructed by x-ray machine equipment. Interview with the Facility Maintenance Manager at the time of the observation acknowledged that the x-ray equipment obstructed the sprinkler heads.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.5
1998 NFPA 25, Section 2-2.1.1

2. Observation of the sprinkler riser room on 09/13/2016 at 2:55 PM revealed the fire riser had been modified from the original installation for the addition of a reduced pressure principle backflow preventer and valves. No hydraulic calculations were posted. Interview with the Facility Maintenance Manager at the time of observation was unaware the hydraulic calculations were missing.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.1.1
1999 NFPA 13, Sections 5-515.4.6.2 and 10-5

3. Observation on 09/15/2016 at 8:52 AM located in the IT/Sever Room revealed 3 ceiling tiles that were missing. Further observation revealed that the sprinkler heads were adjacent to the missing tiles. Interview with the Facility Maintenance Manager at the time of observation acknowledged that the missing ceiling tile would delay the sprinkler heads.

Ref:
2000 NFPA 101, Sections 19.3.5.1, 9.7.1.1, and 9.7.5
1999 NFPA 13, Section 5-6.4.1.1
1998 NFPA 25, Sections 2-2.1.1 and 2-2.7

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Based on observation and staff interview, the facility failed to ensure that the automatic sprinkler systems are installed, and continuously maintained per the requirements of NFPA 13. The findings were:

1. Observation on 09/13/2016 from 10:35 AM to 11:05 AM located on the fourth floor in the IT department adjacent to the bathroom, Business Office Corridor adjacent to room 4310, Business Office Corridor adjacent to Exit door, and throughout the 4th floor area revealed that there were sprinkler heads that were recessed into the ceiling tiles obstructing sprinkler discharge. Interview with the Facility Maintenance Manager at the time of observation acknowledged that the sprinkler heads were obstructed.

2. Observation on 09/13/2016 at 10:56 AM located on the fourth floor in the Environmental Storage Room revealed a sprinkler escutcheon that was missing. Interview with the Facility Maintenance Manager at the time of observation acknowledged that the sprinkler escutcheon was missing.

3. Observation on 09/15/2016 at 11:22 AM located at the auxiliary medical clinic adjacent to Hall D revealed a storage room that had a sprinkler head obstructed. Further observation revealed that there were boxes within 5 inches of the ceiling. Interview with the Facility Maintenance Manager acknowledged that the boxes were obstructing the sprinkler head.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.5
1999 NFPA 13, Section 5-5.5.2

4. Observation on 09/15/2016 at 11:20 AM located at the auxiliary medical clinic revealed two outside overhangs exceeding 4 ft in width at the North East and North exits. Further observation revealed that the assembly for the overhangs were made from combustible material and were not provided with sprinkler protection. Interview with Facility Maintenance Manager at the time of observation stated the building was fully sprinkled.

Ref:
1999 NFPA 12, Section 5-13.8

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Based on observation and staff interview, the facility failed to provide portable fire extinguishers in accordance with NFPA 10. The findings were:
Observation on 09/13/2016 at 3:50 PM located on the 2nd floor receptionist area revealed a fire extinguisher that was not mounted to the wall and sitting on the cabinet. Interview with the Facility Maintenance Manager at the time of observation acknowledged that the extinguisher was not mounted.
Ref:
2000 NFPA 101, Sections 19.3.5.6 and 9.7.4.1
1998 NFPA 10, Section 1-6.10

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Based on observation and staff interview, the facility failed to provide oxygen storage location in accordance with NFPA 99. The findings were:

Observation on 09/15/2016 at 9:02 AM located at the outside oxygen storage tank revealed a receptacle that was lower than 60 inches from the ground. Interview with the Facility Maintenance Manager at the time of observation was unaware of the requirements.

Ref:
1999 NFPA 99, Section 4-3.1.1.2 (4)

Observation on 09/15/2016 at 9:02 AM located at the outside oxygen storage tank revealed combustible/flammable materials located within the fencing adjacent to oxygen tanks. Interview with the Facility Maintenance Manager at the time of observation acknowledged there were cardboard boxes that were stuck in the fence.

Ref:
1999 NFPA 99, Section 4-3.1.1.2 (7)

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Based on observation and staff interview the facility failed to provide an emergency shower in accordance with NFPA 99. The findings were:

Observation on 09/13/2016 at 2:15 PM located in the laboratory revealed that the facility failed to provide the lab with and emergency shower. Interview with the Facility Maintenance Manager acknowledge they were unaware of the requirement.

Ref:
1999 NFPA 99 Section 10.6

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Based on document review and staff interview the facility failed to routinely test the generators in accordance with NFPA 110. The findings were:

Document review on 09/15/2016 at 10:42 AM revealed that the facility was doing monthly generator tests, but failed to provide a KW rating of at least 30% of the name plate rating and/or providing the minimum exhaust gas temperature as recommended by the manufacturer. Interview with the Facility Maintenance Manager at the time of review acknowledged they were unaware of the requirements.

Ref:
2000 NFPA 101, Sections 19.5.1 and 9.1.3
1999 NFPA 110, Sections 6-4.2 and 6-4.2.2

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Based on observation and staff interview the facility failed to demonstrate emergency powered lighting at the generator in accordance with NFPA 99. The findings were:

Observation on 09/15/2016 at 10:00 AM located at the outside generator revealed that the facility did not have emergency battery powered lighting unit(s). Interview with the Facility Maintenance Manager at the time of observation acknowledged that the facility did not have emergency battery powered lighting for their generator.

Ref:
1999 NFPA 99, Section 3-4.2.2.2 (b)5

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Based on observation and staff interview, the facility failed to meet electrical wiring in accordance with NFPA 70. The findings were:
1. Observation on 09/13/2016 at 1:20 PM located in the staff break room 330 and at 1:25 PM located at the women's locker on the 3rd floor revealed receptacles approximately 2 feet away from sinks that were not equipped with a ground-fault circuit-interrupters. Interview with the Facility Maintenance Manager at the time of observation acknowledged the missing ground-fault circuit-interrupters.
Ref:
1999 NFPA 70, Article 210.8

2. Observation on 09/13/2016 at 2:00 PM located in the Laboratory revealed a receptacle with a missing face place adjacent to the refrigerator. Interview with the Facility Maintenance Manager at the time of observation acknowledged the missing face plate.

Ref:
2000 NFPA 101, Sections 19.5.1 and 9.1.2
1999 NFPA 70, Article 370-25