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STANDARD is not met as evidenced by: Through observation and staff interview of the fire alarm system during the tour of the facility, the facility failed to install and maintain the fire alarm system with approved components, devices or equipment in accordance with NFPA 101 Life Safety Code (2012 Edition), section 19.3.4.3.1 and NFPA 72, section 17.7.4.1. Failure to maintain the fire alarm system has the potential to harm all occupants, staff and visitors if the fire alarm system failed to operate as designed if a fire was to occur.

1) Clinic Equipment storage room smoke detector installed to close to HVAC diffuser
2) MRI Hall smoke detector too close to HVAC diffuser

In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. (910 mm) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.

The deficient items were discussed with the Maintenance Staff during the survey and with the CEO and the Maintenance Staff during the exit conference.

STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance.

1-Main Hospital lobby sprinkler head appears to be leaking, rust and foreign material located around joints.
2-Walk-in cooler and freezer located in the kitchen sprinkler heads are older than five years.

Life Safety Code Standards 2012 required automatic sprinkler systems are continuously maintained in reliable operating condition and are installed, inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.
NFPA 25, 2010 section 5.3.1.1.2* Where sprinklers are subjected to harsh environments, including corrosive atmospheres and corrosive water supplies, on a 5-year basis, either sprinklers shall be replaced or representative sprinkler samples shall be tested.

The Director of Maintenance acknowledge the lack of maintenance of the automatic sprinkler system deficiency during record review of the facility.

STANDARD is not met as evidenced by: During observation of the kitchen gas fired cooking equipment it did not meet the requirements of the 2012 Edition of NFPA 54 Fuel and Gas Code 9.6.1.2. This deficient practice could affect all residents, and staff should a fire occur due to failure to operate safely due to non-code compliant. This was evidence by the following.

Gas fired cooking equipment with casters where not limited by a restraining device.

NFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of appliance with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufactures installation instructions.

The Maintenance Director acknowledge lack of a restraining on the gas fired cooking appliances

STANDARD is not met as evidenced by: Based on observation, staff interview, during the course of the survey. It was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems 2010edition Chapter 3 and 5 This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss. This was as evidenced by:

The emergency generator transfer switches 5 and 6 were not equipped with emergency battery back-up lighting.

NFPA 110, Standard for Emergency and Standby Power Systems. 5-3.1 The Level I and Level 2 EPS equipment location shall be provided with batty-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

The emergency power supply system deficiency item was discussed with the CEO and Director of Maintenance during the survey and again at the exit conference.