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Based on observation, the facility failed to maintain the fire alarm system. This was evidenced by a fire alarm circuit disconnecting means that was not distinctly marked. This affected one of two buildings, and could result in a delay in identifying the proper circuit during an electrical emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72 National Fire Alarm and signaling Code, 2010 edition
Chapter 10 Fundamentals
10.1 Application.
10.1.1 The basic functions of a complete fire alarm or signaling
system shall comply with the requirements of this chapter.
10.1.2 The requirements of this chapter shall apply to systems,
equipment, and components addressed in Chapters 12,
14, 17, 18, 21, 23, 24, 26 and 27.
10.2 Purpose. The purpose of fire alarm and signaling systems
shall be primarily to provide notification of alarm, supervisory,
and trouble conditions; to alert the occupants; to summon
aid; and to control emergency control functions.
10.5.5.2 Circuit Identification and Accessibility.
10.5.5.2.1 The location of the dedicated branch circuit disconnecting
means shall be permanently identified at the control unit.
10.5.5.2.2 For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT."
10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking.
10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel.

Findings:

During a facility tour with staff on 6/6/17, the fire alarm system electrical circuit was observed.

Main Hospital

At 1:10 p.m., the emergency panel located in the Nurse Station was observed. Circuit breaker 6 was labeled as the Fire Alarm Control Panel (FACP). There was no red marking on the circuit breaker to identified it as the fire alarm circuit.

Based on observation, document review, and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by not performing a semi-annual FAS inspection. This affected one of two buildings, and could result in a system malfunction or, delay in notification in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1* General.
9.6.1.5* To ensure operational integrity, the fire alarm system
shall have an approved maintenance and testing program
complying with the applicable requirements of NFPA 70, National
Electrical Code, and NFPA 72, National Fire Alarm and Signaling
Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
Chapter 14 Inspection, Testing, and Maintenance
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems,
their initiating devices, and notification appliances shall comply
with the requirements of this chapter.

Table 14.3.1 Visual Inspection Frequencies

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 Testing Frequencies

14.6.2 Maintenance, Inspection, and Testing Records.
14.6.2.1 Records shall be retained until the next test and for
1 year thereafter.
14.6.2.4* A record of all inspections, testing, and maintenance
shall be provided that includes the following information regarding
tests and all the applicable information requested in
Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance,
tests, or combination thereof, and affiliation, business
address, and telephone number
(6) Name, address, and representative of approving agency(
ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat
detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification
systems
(14) Functional test of ability of mass notification system to
silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer ' s
published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system
owner notified, problem corrected/successfully retested,
device abandoned in place)

Findings:

During a facility tour, document review, and interview with staff on 6/6/17, the FAS was observed and records requested.

Main Hospital

At 12 p.m., the facility was observed with an automatic FAS. The record titled, "Annual Fire Alarm Test and Inspection," was completed on 8/5/16. No semi-annual visual inspection, prior to, or after the current annual inspection was available for review. Staff 2 confirmed that the FAS is inspected and tested on an annual basis.

Based on observation, document review, and interview, the facility failed to maintain the battery operated smoke alarms. This was evidenced by failure to test the smoke alarms in accordance with manufacturer's specifications. This affected one of two buildings and could result in the malfunction of smoke alarms.

NFPA 101, Life Safety Code, 2000 edition
39.1.1.3 General. The provisions of Chapter 4, General, shall apply.
39.3.4.2 Initiation. Initiation of the required fire alarm system
shall be by one of the following means:
(1) Manual means in accordance with 9.6.2.1(1)
(2) Means of an approved automatic fire detection system that complies with 9.6.2.1(2) and provides protection throughout the building
(3) Means of an approved automatic sprinkler system that complies with 9.6.2.1(3) and provides protection throughout the building
4.6.12 Maintenance, Inspection, and Testing.
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.

NFPA 72, National Fire Alarm Signaling Code, 2010 edition
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.
14.1.2 The inspection, testing, and maintenance of single and multiple-station smoke and heat alarms and household fire alarm systems shall comply with the requirements of this
chapter.
14.2.1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this Code and conform to the equipment manufacturer ' s published instructions.

Findings:

During a facility tour, document review, and interview with staff on 6/6/17, the battery operated smoke alarms were observed and records for testing were requested.

Outpatient Physical Therapy

At 12:35 p.m., the facility was observed with three single-station battery operated smoke alarms located in the corridor and one room. The manufacturer's testing requirements indicated weekly testing. The facility test log for the smoke alarms indicated that testing was performed monthly instead of weekly. Upon interview, Staff 2 confirmed the finding.

Based on observation, the facility failed to maintain the portable fire extinguishers. This was evidenced by a fire extinguisher that was mounted higher than the maximum allowed height. This affected one of two buildings, and could result in the inability of staff to readily access the fire extinguisher in the event of a fire.

NFPA 101 Life Safety Code, 2012 edition
39.3.5 Extinguishment Requirements. Portable fire extinguishers
shall be provided in every business occupancy in accordance
with 9.7.4.1.
9.7.4.1* Where required by the provisions of another section
of this Code, portable fire extinguishers shall be selected, installed,
inspected, and maintained 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 (18.14 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 lb (18.14 kg) (except wheeled types) shall be installed
so that the top of the fire extinguisher is not more than 31?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 fire extinguisher and the floor be less
than 4 in. (102 mm).

Findings:

During a tour of the facility with staff on 6/6/17, the portable fire extinguishers were observed.

Out Patient Physical Therapy

At 11:20 a.m., the portable ABC class fire extinguisher located in the Service Hall was observed. The fire extinguisher was mounted to the wall with the top of the operative handle at 62 inches above the floor.

Based on observation, the facility failed to maintain the corridor doors. This was evidenced by a corridor door that was obstructed. This affected one of two buildings, and could result in the inability to contain smoke and/or fire to a room.

Findings:

During a tour of the facility with staff on 6/6/17, the corridor doors were observed.

Main Hospital

At 1:15 p.m., the corridor door to the Admissions Office was observed. The door was obstructed from fully closing and latching by an arm chair that was wedged between the door and desk.

Based on document review and interview, the facility failed to conduct fire safety training/drills. This was evidenced by no available records for employee fire equipment training. This affected one of two buildings, and could result in a delayed staff response to a fire emergency.

NFPA 101, Life Safety Code, 2000 edition
39.7.3 Extinguisher Training. Designated employees of business
occupancies shall be periodically instructed in the use of
portable fire extinguishers.

Findings:

During record review and interview with staff on 6/6/17, the employee fire safety training was requested for review.

Outpatient Physical Therapy

At 12:20 p.m., no records for the fire extinguisher training was provided at the time of survey. Upon interview, Staff 2 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the emergency power supply (EPS). This was evidenced by failure to perform the required inspections and testing. This affected one of two buildings, and could potentially result in
a generator failure during an emergency

NFPA 101 Life Safety Code, 2012 edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110 Standard for Emergency and Standby Power Systems, 2010 edition.
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
8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing
of specific gravity when applicable or warranted.
8.4.9* Level 1 EPSS shall be tested at least once within every 36 months.
8.4.9.5 The minimum load for this test shall be as specified in
8.4.9.5.1, 8.4.9.5.2, or 8.4.9.5.3.
8.4.9.5.1 For a diesel-powered EPS, loading shall be not less than 30 percent of the nameplate kW rating of the EPS. A supplemental load bank shall be permitted to be used to meet or exceed the 30 percent requirement.
8.4.9.5.2 For a diesel-powered EPS, loading shall be that which
maintains the minimum exhaust gas temperatures as recommended
by the manufacturer.
8.4.9.5.3 For spark-ignited EPSs, loading shall be the available
EPSS load.
8.4.9.6 The test required in 8.4.9 shall be permitted to be combined with one of the monthly tests required by 8.4.2 and one of the annual tests required by 8.4.2.3 as a single test.
8.4.9.7 Where the test required in 8.4.9 is combined with the annual load bank test, the first 3 hours shall be at not less than the minimum loading required by 8.4.9.5 and the remaining hour shall be at not less than 75 percent of the nameplate kW rating of the EPS.

Findings:

During a facility tour, document review, and interview with staff on 6/6/17, the EPS as observed and records were reqested and reviewed.

Main Hospital

1. At 12:10 p.m., the facility was observed with a diesel fueled 250 kilowatt (KW) EPS. The facility was not able to provide monthly testing and recording of electrolyte specific gravity testing for two of two lead-acid batteries. The record for battery conductance testing was not available. Upon interview, Staff 2 confirmed the finding.

2. At 12:15 p.m., the facility was observed to provide level 1 care. No documentation was available for an every three years, four hour load bank test. Upon interview, Staff 2 confirmed the finding.