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Based on observation, the facility failed to maintain the hazardous rooms per the requirements of:

2012 NFPA 101, 19.3.2.1.2, and 19.3.2.1.3

This deficiency could affect approximately 25 occupants.

Findings include:

On 01/28/2020, during a tour of the facility from 10:15 am to 4:30 pm, the surveyor observed the following hazardous rooms:
1. The Main Electrical/Boiler Room had a gas fueled boiler and the walls between this room and the facility were observed with several unsealed penetrations around multiple condiuts and piping.
2. The Linen Room off of the Kitchen Corridor was over 50 sq. ft. with excessive amounts of linen being stored in this room; the door to this room did not have a self-closing device.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to provide ceilings required for the pendant sprinklers in the facility per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.1.1 (1)
2010 NFPA 13, 8.5.1.1, 8.5.1.2, and 8.5.4.2

This deficiency could affect approximately 5 occupants.

Findings include:

On 01/28/2020, during a tour of the facility from 10:15 am to 4:30 pm, the surveyor observed a 2' x 2' ceiling tile was missing and multiple unsealed penetrations of other ceiling tiles in the IT Room off the Kitchen Corridor.

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

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Based on observation and review of documentation, the facility failed to maintain the automatic sprinklers per the requirements of:

2012 NFPA 101, 9.7.5
2011 NFPA 25, 5.3.1.1.1.6

This deficiency could affect approximately 15 occupants.

Findings include:

On 01/28/2020, during a tour of the facility from 10:00 am to 4:30 pm, the facility failed to provide documentation that the dry sprinklers installed in 2007, located on Loading Dock and in the walk in cooler and freezer had been replaced or a representative sample tested within 10 years of installation.

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

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Based on observation, the facility failed to install the portable fire extinguishers per the requirements of:

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

This deficiency could affect approximately 10 occupants.

Findings include:

On 01/28/2020, during a tour of the facility from 10:00 am to 4:30 pm, the surveyor observed two portable fire extinguishers installed approximately 65" from the floor to the top of the fire extinguishers.

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

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Based on observation, the facility failed to maintain corridor doors per the requirements of:

2012 NFPA 101, 19.3.6.3.10, 19.3.6.3.2 (2), and 7.2.1.5.10.1
42 CFR 483.90 (a) (1) (ii)
S&C-07-18

This deficiency could affect approximately 30 occupants.

Findings include:

On 01/28/2020, during a tour of the facility from 10:15 am to 4:30 pm, the surveyor observed the following:
1. The corridor door to the Janitor's Room on the Kitchen Corridor was impeded from closing by high spot on the finished floor.
2. The Dining Room corridor door on the Kitchen Corridor had a gap greater than 1/2 inch between the door and door frame when the door was closed and latched.
3. The releasing mechanism (door handle) of the Linen Room on the Kitchen Corridor was approximately 56.5" above the finished floor.

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

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Based on observation, the facility failed to prohibit a portable space heating device per the requirements of:

2012 NFPA 101, 19.7.8

This deficiency could affect approximately 5 occupants.

Findings include:

On 01/28/2020, during a tour of the facility from 10:00 am to 4:30 pm, the surveyor observed a portable space heating device that was located in the Doctors' Lounge. The facility was unable to provide documentation that the heating element did not exceeding 212 degrees.

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

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Based on review of documentation, the facility failed to maintain the testing of the diesel generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, 6.5.4.2, and 6.4.4.2
2010 NFPA 110, 1.3, 8.4.1, 8.4.2, 8.4.2.3, 8.3.8, and 8.4.9

This deficiency could affect approximately all occupants.

Findings include:

On 01/28/2020, during a tour of the facility from 10:15 am to 4:30 pm, the facility failed to:

1. Test the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature OR under operating temperature conditions at not less than 30% of the nameplate kW rating OR provide an annual 1.5 hour supplemental load test at not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less 75% of the EPS nameplate KW rating for one continuous hour for a total test duration of not less than 1.5 continuous hours.
2. Have a fuel quality test performed at least annually using tests approved by ASTM standards.
3. Have a Level 1 EPSS test conducted within the past 36 months.

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

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Based on observation, the facility failed to maintain the electrical equipment per the requirements of:

2012 NFPA 99, 10.2.4
2011 NFPA 70, 400.8

This deficiency could affect approximately 5 occupants.

Findings include:

On 01/28/2020, during a tour of the facility from 10:15 am to 4:30 pm, the surveyor observed a printer plugged in to an approximately 25' orange temporary electrical extension cord in the OP Surgery Office.

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