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The facility failed to ensure the occupancy separation between the hospital and the attached assisted living building had a 2-hour fire resistance rating. Observation determined unsealed openings around through-wall data cable penetrations above the fire-rated door in the two-hour fire resistant rated occupancy separation wall between the hospital and the attached assisted living building. Failure to ensure two-hour fire resistant rated occupancy separation walls increases the risk of death or injury due to fire. This deficiency affected one (1) of two (2) occupancy separation walls.

One-story Existing Health Care Occupancy buildings of Type III (200) construction are required to be protected throughout with an automatic fire sprinkler system.

The facility failed to provide an automatic fire sprinkler system throughout the facility that meets the requirements of NFPA 13, Standard for Installation of Sprinkler Systems.

Observation determined the structural walls were concrete block and the roof assembly was constructed of combustible wood supports and wood boards. The building was not protected throughout with an automatic fire sprinkler system. Failure to provide a building of construction Type III (200) with an automatic fire sprinkler system increases the risk of injury and death.This deficiency affected the entire building.

The facility failed to ensure corridors were separated from use areas by walls constructed with at least a ½-hour fire resistance rating.

1) Observation determined the corridor walls throughout the basement and main floor were not maintained as ½-hour fire resistant rated wall assemblies. The holes through the corridor walls caused by pipe, electrical conduit, air duct, and low-voltage wire penetrations were not adequately sealed with fire rated material. Failure to ensure corridor walls had a ½-hour fire resistant rating increases the risk of injury and death. This deficiency affected the entire facility.2) The newly installed air handler in the basement corridor space was observed to have a transfer grill in the wall which failed to provide the required ½-hour fire resistance rating between the room and the corridor. Failure to ensure corridor walls have a ½-hour fire resistant rating increases the risk of injury and death. This deficiency affected the entire basement.

The facility failed to ensure the corridor doors were provided with automatic latching hardware to keep the doors closed.

Observation determined the west door leaf of the double doors to the first floor CT Scan Room were equipped with manual flush bolt latches rather than the required automatic latching hardware.Failure to equip corridor doors with automatic latching hardware increases the risk of injury or death.

This deficiency affected one (1) of numerous doors in the building.

The facility failed to ensure stairways were enclosed with construction having a fire resistance rating of at least one hour. Observation determined the northeast stair enclosure had unsealed spaces around a four (4) inch through-wall pipe penetration to the first floor corridor.Failure to enclose vertical openings with one-hour fire resistant construction increases the risk of injury and death.This deficiency affected the entire first floor.

The facility failed to separate hazardous areas from other spaces with one-hour fire resistive rated partitions and self-closing fire-rated door assemblies.

Observation determined:1) The door to the first floor Trash/Red Bag Storage Room was not equipped with a self-closing device. 2) The door between the basement Storage Room and the Maintenance Office was not equipped with a self-closing device. 3) The door between the Maintenance Office/Storage area and the corridor was not equipped with a self-closing device. 4) The wall between the basement Storage Room and the Maintenance Office had unsealed through-wall penetrations. 5) Several unsealed openings were observed around data cables that penetrated the corridor wall from the basement Elevator Equipment Room. 6) Several unsealed openings were observed where portions of the plaster and mesh ceiling were missing from the Kitchen Storage Room which measured greater than 50 sq.ft. in area.Failure to ensure hazardous areas are separated by 3/4-hour fire rated self-closing doors and one-hour fire-rated walls increases the risk of injury and death.This deficiency affected five (5) of eleven (11) hazardous areas.

The facility failed to ensure that exit stairways were enclosed with construction having a fire resistance rating of at least one-hour to provide a continuous path of escape with protection provided against fire or smoke from other parts of the building.

Observation determined the north and south exit stairs from the basement discharged onto the main floor and were not arranged to provide a continuous fire resistant enclosure to the exterior of the building. Failure to ensure a continuous path of escape with protection provided against fire or smoke from other parts of the building increases the risk of injury or death.This deficiency affected two (2) of two (2) exits from the basement.

During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.4.

The facility failed to ensure exit access was readily accessible at all times. Observation determined the door to the basement Central Storage Room door opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.Failure to ensure exit access was readily accessible at all times increases the risk of death or injury due to fire. This deficiency affected one (1) of numerous doors in the facility.

The facility failed to provide emergency lighting in corridors and at the exterior of the building leading to the public way. Observation and interview with the maintenance staff determined the corridor lighting in the exit corridor between the hospital and the clinic was not interconnected to automatically provide emergency lighting to the interior and exterior of the building spaces between the hospital and clinic in the event normal lighting provided by commercial power is interrupted.Failure to provide emergency lighting in accordance with NFPA 101 increases the risk of death or injury due to fire.

This deficiency affected the west exit path from the west exit to the public way.

The facility failed to test the fire alarm system as required.

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required by NFPA 72, National Fire Alarm Code. Load voltage tests were conducted annually with the last test performed on 08/07/2015. No semiannual load voltage test was documented six months prior to this date.

Failure to test and maintain the fire alarm system as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of two (2) required load voltage tests of the batteries in the last year. The fire alarm system serves the entire facility.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.

Smoke detectors must not be located in a direct airflow nor closer than 3 ft. (1 m) from an air supply diffuser or return air opening. NFPA 72 A-2-3.5.1

The facility failed to ensure smoke detectors were installed in accordance with NFPA 72, National Fire Alarm Code.

Observation determined smoke detectors were located less than three (3) feet from direct airflow from air supply diffusers in the Operating Room and Patient Rooms throughout the building. Failure to install smoke detectors in accordance with National Fire Alarm Code requirements increases the risk of injury or death. This deficiency affected the Operating Room and Patient Rooms throughout the facility.

The facility failed to ensure the automatic fire sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. Observation determined one (1) of one (1) sprinklers in the basement Kitchen Storage Room had paint on the sprinkler deflector and may not operate at the correct temperature. Failure to inspect, test and maintain the components of the domestic automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire. This deficiency affected numerous inspections, tests and components of the domestic automatic fire sprinkler system which serves Kitchen Storage Room and select areas of the facility.

The facility failed to ensure the relative humidity was maintained equal to or greater than 35% in the Operating Room.

Records review determined the relative humidity readings recorded indicated the relative humidity was maintained at 19.5% in the Operating Room.Failure to maintain the relative humidity at levels in accordance with NFPA 99 increases the risk of injury and death. This deficiency affected patient safety in the Operating Room.

1) Existing life safety features obvious to the public, if not required by the Code, must be either maintained or removed. 4.6.12.2

Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 4.6.12.3

Emergency illumination shall be provided for not less than 1½ hours in the event of failure of normal lighting. 7.9.2.1

A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1½ hours. 7.9.3. Records review determined monthly and annual testing of the emergency battery-powered emergency lighting system was not documented.

The facility failed to ensure the emergency lighting was in proper operating condition to provide 1½ hours of emergency illumination in the event of failure of normal lighting.

Failure to test and maintain the emergency lights in accordance with NFPA 101 increases the risk of death or injury due to fire.

This deficiency affected the entire facility.

2) Portable fire extinguishers shall be maintained in a fully charged and operable condition, NFPA 10, Standard for Portable Fire Extinguishers. 1-6.2. The facility failed to inspect and maintain portable fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Observation determined two (2) of two (2) portable fire extinguishers were not inspected in January, 2016. The last date of an annual maintenance documented was 08/2010. Failure to ensure portable fire extinguishers are maintained in accordance with NFPA 10 increases the risk of death or injury due to fire.

This deficiency affected the entire facility. 3) Portable fire extinguishers shall be maintained in a fully charged and operable condition, and kept in their designated places at all times when they are not being used. Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. NFPA 10, Standard for Portable Fire Extinguishers. 1-6.3.The facility failed to ensure portable fire extinguishers were kept in designated locations when not being used. One (1) of two (2) extinguishers was located behind a copy machine and file cabinet. Failure to ensure ready access to fire extinguishers is provided to all staff increases the risk of death or injury due to fire.

This deficiency affected the entire building.4) The facility failed to ensure two (2) of two (2) battery powered smoke detectors were tested weekly or in accordance with the manufacturer guidelines. Written documentation must be maintained.Failure to test the battery-powered smoke alarms weekly or in accordance with guidelines from the manufacturer increases the risk of death or injury due to fire.

This deficiency affected the entire building.5) A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. Doors shall be operable with not more than one releasing operation. Keyed locks, dead bolt locks and multi-latching devices create an impediment to egress from habitable spaces. Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. 7.2.1.5.1

The facility failed to ensure exit access was readily accessible at all times with not more than one releasing operation.

Observation determined two (2) of two (2) exits were equipped with lever latch hardware and separate deadbolt locks, which require more than one releasing operation.

Failure to ensure exits are accessible with door unlocking hardware that will not require more than one (1) action to unlock an exit door increases the risk of injury or death.This deficiency affected two (2) of two (2) exits from the building. 6) The facility failed to develop and implement a smoking policy.Observation and records review determined the facility lacked a written smoking policy.

Failure to develop, implement and distribute a comprehensive smoking policy increases the risk of injury and death.

This deficiency affected the entire building.

1) All Level 1 and Level 2 installations of an emergency generator must have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition. Ref: 2000 NFPA 101 Section 19.2.9.1, 7.9.2.3, 1999 NFPA 110 Section 3-5.5.6 Observation determined there was no remote emergency stop switch for the generator located outside of the Generator Room. Failure to ensure the emergency generator was in compliance with NFPA 110, increases the risk of death or injury due to fire. The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.
2) A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. NFPA 99 3-4.1.1.15 The facility failed to ensure the emergency generator was in compliance with NFPA 99, Standard for Health Care Facilities. Observation determined there was no remote annunciator located outside of the Generator Room at a work site readily observable by personnel. Failure to ensure the emergency generator was in compliance with NFPA 99 increases the risk of death or injury due to fire. The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.3) Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6 and NFPA 99 Standard for Health Care Facilities 1999 Edition, 3-4.4.1 Maintenance and Testing of Essential Electrical System.
Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Records review determined the emergency generator was not tested in accordance with these requirements. No generator test records were available between April, 2015 and October, 2015.Failure to ensure emergency generators are tested and maintained in compliance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire. The deficiency affected one (1) of one (1) emergency generator which provides emergency power to the entire facility.

Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. NFPA 101 Life Safety Code, 4.6.12.1.

The facility failed to ensure the electrical wiring was maintained in accordance with NFPA 70, National Electrical Code.

Observation determined:1) The presence of Romex electrical wiring with an electrical plug attached that extended through the north basement wall from the Elevator Equipment Room to an inaccessible location beneath the building.

Failure to ensure the electrical wiring is functional and operable increases the risk of injury and death due to fire.

The deficiency affected one (1) of numerous electrical conductors in the facility.

2) The facility failed to ensure ground fault circuit interrupter (GFCI) receptacles were maintained in operable condition.

a) Testing of the GFCI electrical receptacles determined the GFCI receptacle located in the first floor Clean Utility Room failed to trip when tested.b) Testing of the GFCI electrical receptacles determined the GFCI receptacle located in the first floor Soiled Utility Room failed to reset when tested.

Failure to ensure the electrical wiring is functional and operable increases the risk of injury and death due to fire.

The deficiency affected two (2) of numerous GFCI protected receptacles in the facility.

The facility failed to ensure the occupancy separation between the hospital and the attached assisted living building had a 2-hour fire resistance rating. Observation determined unsealed openings around through-wall data cable penetrations above the fire-rated door in the two-hour fire resistant rated occupancy separation wall between the hospital and the attached assisted living building. Failure to ensure two-hour fire resistant rated occupancy separation walls increases the risk of death or injury due to fire. This deficiency affected one (1) of two (2) occupancy separation walls.

One-story Existing Health Care Occupancy buildings of Type III (200) construction are required to be protected throughout with an automatic fire sprinkler system.

The facility failed to provide an automatic fire sprinkler system throughout the facility that meets the requirements of NFPA 13, Standard for Installation of Sprinkler Systems.

Observation determined the structural walls were concrete block and the roof assembly was constructed of combustible wood supports and wood boards. The building was not protected throughout with an automatic fire sprinkler system. Failure to provide a building of construction Type III (200) with an automatic fire sprinkler system increases the risk of injury and death.This deficiency affected the entire building.

The facility failed to ensure corridors were separated from use areas by walls constructed with at least a ½-hour fire resistance rating.

1) Observation determined the corridor walls throughout the basement and main floor were not maintained as ½-hour fire resistant rated wall assemblies. The holes through the corridor walls caused by pipe, electrical conduit, air duct, and low-voltage wire penetrations were not adequately sealed with fire rated material. Failure to ensure corridor walls had a ½-hour fire resistant rating increases the risk of injury and death. This deficiency affected the entire facility.2) The newly installed air handler in the basement corridor space was observed to have a transfer grill in the wall which failed to provide the required ½-hour fire resistance rating between the room and the corridor. Failure to ensure corridor walls have a ½-hour fire resistant rating increases the risk of injury and death. This deficiency affected the entire basement.

The facility failed to ensure the corridor doors were provided with automatic latching hardware to keep the doors closed.

Observation determined the west door leaf of the double doors to the first floor CT Scan Room were equipped with manual flush bolt latches rather than the required automatic latching hardware.Failure to equip corridor doors with automatic latching hardware increases the risk of injury or death.

This deficiency affected one (1) of numerous doors in the building.

The facility failed to ensure stairways were enclosed with construction having a fire resistance rating of at least one hour. Observation determined the northeast stair enclosure had unsealed spaces around a four (4) inch through-wall pipe penetration to the first floor corridor.Failure to enclose vertical openings with one-hour fire resistant construction increases the risk of injury and death.This deficiency affected the entire first floor.

The facility failed to separate hazardous areas from other spaces with one-hour fire resistive rated partitions and self-closing fire-rated door assemblies.

Observation determined:1) The door to the first floor Trash/Red Bag Storage Room was not equipped with a self-closing device. 2) The door between the basement Storage Room and the Maintenance Office was not equipped with a self-closing device. 3) The door between the Maintenance Office/Storage area and the corridor was not equipped with a self-closing device. 4) The wall between the basement Storage Room and the Maintenance Office had unsealed through-wall penetrations. 5) Several unsealed openings were observed around data cables that penetrated the corridor wall from the basement Elevator Equipment Room. 6) Several unsealed openings were observed where portions of the plaster and mesh ceiling were missing from the Kitchen Storage Room which measured greater than 50 sq.ft. in area.Failure to ensure hazardous areas are separated by 3/4-hour fire rated self-closing doors and one-hour fire-rated walls increases the risk of injury and death.This deficiency affected five (5) of eleven (11) hazardous areas.

The facility failed to ensure that exit stairways were enclosed with construction having a fire resistance rating of at least one-hour to provide a continuous path of escape with protection provided against fire or smoke from other parts of the building.

Observation determined the north and south exit stairs from the basement discharged onto the main floor and were not arranged to provide a continuous fire resistant enclosure to the exterior of the building. Failure to ensure a continuous path of escape with protection provided against fire or smoke from other parts of the building increases the risk of injury or death.This deficiency affected two (2) of two (2) exits from the basement.

During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.4.

The facility failed to ensure exit access was readily accessible at all times. Observation determined the door to the basement Central Storage Room door opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.Failure to ensure exit access was readily accessible at all times increases the risk of death or injury due to fire. This deficiency affected one (1) of numerous doors in the facility.

The facility failed to provide emergency lighting in corridors and at the exterior of the building leading to the public way. Observation and interview with the maintenance staff determined the corridor lighting in the exit corridor between the hospital and the clinic was not interconnected to automatically provide emergency lighting to the interior and exterior of the building spaces between the hospital and clinic in the event normal lighting provided by commercial power is interrupted.Failure to provide emergency lighting in accordance with NFPA 101 increases the risk of death or injury due to fire.

This deficiency affected the west exit path from the west exit to the public way.

The facility failed to test the fire alarm system as required.

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required by NFPA 72, National Fire Alarm Code. Load voltage tests were conducted annually with the last test performed on 08/07/2015. No semiannual load voltage test was documented six months prior to this date.

Failure to test and maintain the fire alarm system as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of two (2) required load voltage tests of the batteries in the last year. The fire alarm system serves the entire facility.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.

Smoke detectors must not be located in a direct airflow nor closer than 3 ft. (1 m) from an air supply diffuser or return air opening. NFPA 72 A-2-3.5.1

The facility failed to ensure smoke detectors were installed in accordance with NFPA 72, National Fire Alarm Code.

Observation determined smoke detectors were located less than three (3) feet from direct airflow from air supply diffusers in the Operating Room and Patient Rooms throughout the building. Failure to install smoke detectors in accordance with National Fire Alarm Code requirements increases the risk of injury or death. This deficiency affected the Operating Room and Patient Rooms throughout the facility.

The facility failed to ensure the automatic fire sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. Observation determined one (1) of one (1) sprinklers in the basement Kitchen Storage Room had paint on the sprinkler deflector and may not operate at the correct temperature. Failure to inspect, test and maintain the components of the domestic automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire. This deficiency affected numerous inspections, tests and components of the domestic automatic fire sprinkler system which serves Kitchen Storage Room and select areas of the facility.

The facility failed to ensure the relative humidity was maintained equal to or greater than 35% in the Operating Room.

Records review determined the relative humidity readings recorded indicated the relative humidity was maintained at 19.5% in the Operating Room.Failure to maintain the relative humidity at levels in accordance with NFPA 99 increases the risk of injury and death. This deficiency affected patient safety in the Operating Room.

1) Existing life safety features obvious to the public, if not required by the Code, must be either maintained or removed. 4.6.12.2

Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 4.6.12.3

Emergency illumination shall be provided for not less than 1½ hours in the event of failure of normal lighting. 7.9.2.1

A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1½ hours. 7.9.3. Records review determined monthly and annual testing of the emergency battery-powered emergency lighting system was not documented.

The facility failed to ensure the emergency lighting was in proper operating condition to provide 1½ hours of emergency illumination in the event of failure of normal lighting.

Failure to test and maintain the emergency lights in accordance with NFPA 101 increases the risk of death or injury due to fire.

This deficiency affected the entire facility.

2) Portable fire extinguishers shall be maintained in a fully charged and operable condition, NFPA 10, Standard for Portable Fire Extinguishers. 1-6.2. The facility failed to inspect and maintain portable fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Observation determined two (2) of two (2) portable fire extinguishers were not inspected in January, 2016. The last date of an annual maintenance documented was 08/2010. Failure to ensure portable fire extinguishers are maintained in accordance with NFPA 10 increases the risk of death or injury due to fire.

This deficiency affected the entire facility. 3) Portable fire extinguishers shall be maintained in a fully charged and operable condition, and kept in their designated places at all times when they are not being used. Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. NFPA 10, Standard for Portable Fire Extinguishers. 1-6.3.The facility failed to ensure portable fire extinguishers were kept in designated locations when not being used. One (1) of two (2) extinguishers was located behind a copy machine and file cabinet. Failure to ensure ready access to fire extinguishers is provided to all staff increases the risk of death or injury due to fire.

This deficiency affected the entire building.4) The facility failed to ensure two (2) of two (2) battery powered smoke detectors were tested weekly or in accordance with the manufacturer guidelines. Written documentation must be maintained.Failure to test the battery-powered smoke alarms weekly or in accordance with guidelines from the manufacturer increases the risk of death or injury due to fire.

This deficiency affected the entire building.5) A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. Doors shall be operable with not more than one releasing operation. Keyed locks, dead bolt locks and multi-latching devices create an impediment to egress from habitable spaces. Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. 7.2.1.5.1

The facility failed to ensure exit access was readily accessible at all times with not more than one releasing operation.

Observation determined two (2) of two (2) exits were equipped with lever latch hardware and separate deadbolt locks, which require more than one releasing operation.

Failure to ensure exits are accessible with door unlocking hardware that will not require more than one (1) action to unlock an exit door increases the risk of injury or death.This deficiency affected two (2) of two (2) exits from the building. 6) The facility failed to develop and implement a smoking policy.Observation and records review determined the facility lacked a written smoking policy.

Failure to develop, implement and distribute a comprehensive smoking policy increases the risk of injury and death.

This deficiency affected the entire building.

1) All Level 1 and Level 2 installations of an emergency generator must have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition. Ref: 2000 NFPA 101 Section 19.2.9.1, 7.9.2.3, 1999 NFPA 110 Section 3-5.5.6 Observation determined there was no remote emergency stop switch for the generator located outside of the Generator Room. Failure to ensure the emergency generator was in compliance with NFPA 110, increases the risk of death or injury due to fire. The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.
2) A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. NFPA 99 3-4.1.1.15 The facility failed to ensure the emergency generator was in compliance with NFPA 99, Standard for Health Care Facilities. Observation determined there was no remote annunciator located outside of the Generator Room at a work site readily observable by personnel. Failure to ensure the emergency generator was in compliance with NFPA 99 increases the risk of death or injury due to fire. The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.3) Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6 and NFPA 99 Standard for Health Care Facilities 1999 Edition, 3-4.4.1 Maintenance and Testing of Essential Electrical System.
Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Records review determined the emergency generator was not tested in accordance with these requirements. No generator test records were available between April, 2015 and October, 2015.Failure to ensure emergency generators are tested and maintained in compliance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire. The deficiency affected one (1) of one (1) emergency generator which provides emergency power to the entire facility.

Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. NFPA 101 Life Safety Code, 4.6.12.1.

The facility failed to ensure the electrical wiring was maintained in accordance with NFPA 70, National Electrical Code.

Observation determined:1) The presence of Romex electrical wiring with an electrical plug attached that extended through the north basement wall from the Elevator Equipment Room to an inaccessible location beneath the building.

Failure to ensure the electrical wiring is functional and operable increases the risk of injury and death due to fire.

The deficiency affected one (1) of numerous electrical conductors in the facility.

2) The facility failed to ensure ground fault circuit interrupter (GFCI) receptacles were maintained in operable condition.

a) Testing of the GFCI electrical receptacles determined the GFCI receptacle located in the first floor Clean Utility Room failed to trip when tested.b) Testing of the GFCI electrical receptacles determined the GFCI receptacle located in the first floor Soiled Utility Room failed to reset when tested.

Failure to ensure the electrical wiring is functional and operable increases the risk of injury and death due to fire.

The deficiency affected two (2) of numerous GFCI protected receptacles in the facility.