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Based on observations, the facility failed to comply with the required smoke passage resistance in a hazardous area.

The findings included:

Observation on 02/09/2017 between 1:51 PM and 2:49 PM, revealed penetrations in a fire/smoke barrier of a hazerdous area in the following locations:
a. Electrical room #4, 4 inch hole in the ceiling above the boiler
b. Electrical room #4, 1 inch copper line passing though the wall and into the drain
c. Electrical room #4, two 1.5 inch copper line penetration behind the boiler
d. Rehab mechanical room, 3 inch sprinkler pipe penetration above the compressor
e. Electrical room #5, 1.5 inch electrical conduate penetrating the ceiling
NFPA 101, 8.5.6.2 (2012 Edition)

The maintenance director and staff were present during these findings and the CEO acknowledged the deficiencies during the exit conference conducted on 02/09/2017.

Based on observations, the facility failed to comply with the standards of maintaining the sprinkler system in accordance with NFPA 25.

The findings included:

1. Observations on 02/09/2017 between 2:10 PM and 2: 15 PM, revealed sprinklers out of orientation in the following areas:
a. Rehab Corridoor, outside of the restroom next to room 153
b. Administration office, two sprinklers inside of the marketing office
NFPA 101, 19.3.5.1 (2012 Edition), NFPA 101,9.7.1.1 (2012 Edition), NFPA 13, 26.1 (2010 Edition), NPFA 25, 5.3.1.1.3 (2011 Edition)

2. Observation on 02/09/2017 at 2:45 PM, revealed the facility failed to maintain the proper type of spare sprinklers. (standard reponse pendant and side wall quick response) NFPA 101, 19.3.5.1 (2000 Edition), NFPA 101,9.7.1.1 (2000 Edition), NFPA 13, 26.1 (2010 Edition), NFPA 25, 5.4.1.4 (2011 Edition)

The maintenance director and staff were present during these findings and the CEO acknowledged the deficiencies during the exit conference conducted on 02/09/2017.

Based on observations, the facility failed to comply with the use of extention cords and power strips as required by NFPA 70 and CMS-14-46-LSC.

The findings included:

1. Observation on 02/09/2017 between 2:00 PM and 2:26 PM, revealed the an extention cord being used for permanant use in the following areas:
a. Medical records, behind the first desk used to power a computer
b. Gift shop, used to power a soda machine
c. Lab, on the desk used to power a computer
NFPA 99, 10.2.4.2 (2012 Edition), NFPA 99, 10.24.2.3 (2012 Edition), NFPA 99, 10.2.3 (2012 Edition),

2. Observation on 02/09/2017 at 2:00 PM, revealed three multi plug power strips being used back to back (daisy chained) in the lab.
CMS-14-46-LSC.

The maintenance director and staff were present during these findings and the CEO acknowledged the deficiencies during the exit conference conducted on 02/09/2017.