HospitalInspections.org

Based on observation and staff interview, the facility failed to maintain the lay-in tile ceiling in two areas. The fire-rated ceiling tile assembly had been altered reducing the construction type to an unprotected non-combustible. This deficient practice affects two of five smoke compartments on the first floor and all staff and visitors in those compartments. This facility has a capacity of 124 and a census of 78 residents.

Findings include:

Observation and staff interview on 01/06/14, revealed the following deficiencies with the lay-in tile ceiling:
1. There was a two inch hole in the ceiling tile by the West exit of the Maintenance Shop #1371.
2. There was a two inch hole in the ceiling tile by the Catering dishes in the Kitchen.

Maintenance Staff A confirmed these observations during the survey process.

Based on observation and interview, this facility is not assuring that seven smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all occupants of the building, including staff, visitors and residents in fourteen of thirty-five smoke zones. This facility has a capacity of 126 with a census of 78 residents.

Findings include:

Observation and staff interview on 01/06-07/14, revealed the following deficiencies with smoke barriers:
1. There was a one inch penetration around blue wiring in the smoke barrier by stairwell #5 on the 1st floor.
2. There was a 1/2 inch penetration around blue wiring in the smoke barrier adjacent from room #1030.
3. There was a 1/2 inch penetration in the smoke barrier by room #1606.
4. There was an open 3 inch conduit in the smoke barrier by stairwell #5 on the 4th floor.
5. There was an open 4 inch conduit in the smoke barrier from the hospital to the vestibule for the Wendt Cancer Center.
6. There was an open conduit in the smoke barrier by room #2012.
7. There was an open 4 inch conduit in the smoke barrier from the Wendt Cancer Center to the vestibule for the Hospital.
According to the facility layout, these are required barriers. Maintenance Staff A confirmed these observations.

NFPA standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected four of the thirty-five smoke compartments in the building. The facility has 126 certified beds and at the time of the survey the census was 78.

Findings include:

Observation and interview on 01/07/14, revealed the following smoke door deficiencies:
1. The elevator lobby doors by room #4411 did not close and latch into the frame properly.
2. The 3rd floor elevator lobby doors for Elevator E F did not latch into the frame properly.
3. The smoke doors by room #3346, south leaf, did not close completely.
Maintenance Staff A confirmed these observations during the survey process.

NFPA standard: Requires doors in smoke barriers to be self-closing and resist the passage of smoke, 2000 NFPA 101, 19.3.7.6

Based on observation and interview, the facility failed to provide separation of one hazardous area from other compartments. The area of deficient practice affected one of eight smoke compartments on the third floor. This facility has a capacity of 126 and a census of 78 residents.

Findings include:

Observation and interview on 01/07/14, revealed the door to Soiled Linen room #3415 did not latch into the frame. Maintenance Staff A confirmed these observations.

Hazardous area with Sprinkler
NFPA standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have closers and positive latches. 2000 NFPA 101, 19.3.2.1

Based on observation and interview, the facility is not providing exiting out of one area without special knowledge of the doors locking device. This deficient practice affects all occupants including staff, visitors and residents, in the Emergency Room. The facility has a capacity of 126 and a census of 78 residents.

Findings include:

Observation and interview on 01/07/14, revealed the Main door and exit door by room #2012 for the Emergency Room did not release the mag lock when the panic bar was activated. The doors would release when a button on the wall was pushed, however, there was not any indication to push the button for exiting. Maintenance Staff A said the magnetic locks were installed for security purposes to the Emergency Room.

NFPA standard: 2000 NFPA 101, 19.

Based on record review and interview, the facility failed to document the emergency egress lighting monthly, documentation was dated only from September 2013. This deficient practice affects thirty-five of thirty-five smoke compartments and all occupants of the facility. This facility has a capacity of 126 and a census of 78 residents.

Findings include:

Observation of the facility's maintenance records and staff interview on 01/06/14, revealed the absence of documentation regarding the testing of the emergency battery lighting system. According to Maintenance Staff A, the lights were tested monthly, but there was no documentation to show that the monthly tests were conducted before September 2013.

NFPA standard: Requires a documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours. 2000 NFPA 101, 7.9.3



Finley Hospital Therapy Services


Based on record review and interview, the facility failed to test and document the emergency egress lighting monthly and annually. This deficient practice affects one of one compartments and all occupants of the facility. This facility is business occupancy.

Findings include:

Observation of the facility's maintenance records and interview on 01/08/14, revealed the absence of documentation regarding the testing of the emergency battery lighting system. According to Administrative Staff A, the emergency egress lighting had not been tested monthly for 30 seconds nor an annual test for 90 minutes under load been performed.


NFPA standard: Requires a documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours. 2000 NFPA 101, 7.9.3

Kehl Diabetes/Babka Wellness

Based on observation and interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff and visitors. This facility is business occupancy.

Findings include:

Observation and interview on 01/08/14, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the Electrical room, electrical breaker #53 was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice. Maintenance Staff verified this observation.

Based on observation and record review, the facility failed to provide a properly tested and maintained fire alarm system. All of the facilities were directly affected by the deficient practice. The facilities were business occupancy.

Findings include:

A review of the inspection records for the fire alarm system on 01/08/14, revealed Finley Rehab Westmark/Pedeatrics Rehab and Kehl Diabetes/Babka Wellness did not have documentation from current fire alarm inspections. Maintenance Staff A confirmed observations during the survey process.

NFPA standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per the 1999 edition of NFPA 72, table 7-3.2. and listed as required by NFPA 72, 7-5.2.2

Based on observation and interview, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of National Fire Protection Association (NFPA) 25, and the 1999 edition of National Fire Protection Association (NFPA) 13. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants in three smoke zones at risk in the event of a fire. The census was 78 with a capacity of 126.

Findings include:

Observation and interview on 01/06-08/14, revealed the following deficiencies with the sprinkler system:
1. A missing escutcheon plate for a sprinkler head in the middle of the Maintenance Shop #1371.
2. A missing escutcheon plate for the sprinkler head by the Kitchen door #1508 in the corridor.
3. Eight missing escutcheon plates for sprinkler heads located in the West exit path of the Finley Hospital Therapy Services Building.
4. One sprinkler head with paint of the fusible link in the West exit path of the Finley Hospital Therapy Services Building.

These observations were verified with Maintenance Staff A.


-NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1

NFPA Standard: The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 1-4.4

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. NFPA 25, 2-2.1.1

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water-filled piping is installed; and replacing worn or missing fire hose or nozzles. NFPA 25, 1-11.3

NFPA Standard: Unacceptable obstructions to spray patterns shall be corrected. 1998 NFPA 25, 2-2.1.2

Finley Rehab Westmark/Pedeatric Rehab

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Assocation 25. This deficient practice affects all occupants in the facility. The facility is business occupancy.

Findings include:

Observation and interview on 01/08/14, revealed the facility did not have documentation of a current sprinker inspection. The last inspection according to the tag on the system was 2009. Maintenance Staff A verified this finding.


NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1

Finley Hospital Therapy Services

Based on observation and interview, the facility failed to maintain and test fire extinguishers as required. The deficient practice could affect staff and visitors in the facility. The facility is business occupancy.

Findings include:

Observation and interview on 01/08/14, revealed all of the fire extinguishers in the facility were missing monthly inspections. Maintenance Staff A verified these findings.


Actual NFPA standard: Fire extinguishers shall be inspected when placed in service and thereafter at approximately 30-day intervals per 1998 NFPA 10, 4-3.1

Babka Wellness


Based on observation and interview, the facility did not maintain one egress path. This deficient practice affects all occupants and visitors. This facility is business occupancy.

Findings include:

Observation and interview on 01/08/14, revealed three chairs outside of the Fitness room in the exit corridor. These chairs block the exit corridor allowing approximately less than 36 inches clear walkway. Maintenance Staff A verified this finding.

The facility failed to provide draperies and curtains that are in accordance with provisions of National Fire Protection Association (NFPA) 13. This has the potential of affecting all the residents, staff and visitors in two of thirty-five smoke zones. This facility has a capacity of 126 and a census of 78 residents.

Findings include:

Observation and interview on 01/07/14, revealed the following areas had curtains with less than 1/2 inch mesh on the top of the curtains:
1. Rooms #524, #523, #522.
2. Entire Acute Rehab wing.
Maintenance Staff A confirmed these observations.

NFPA Standard: Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations in health care occupancies are in accordance with the provisions of 10.3.1 and NFPA 13, Standards for the Installation of Sprinkler Systems. 2000 NFPA 13

Based on observation and interview, the facility failed to maintain the relief valve height from the floor of one water heater. This deficient practice affects all occupants in the Kitchen. The facility has a capacity of 126 and the census of 78 residents.

Finding include:

Observation and interview on 1/06/14, revealed the relief valve pipe for the water heater in the Kitchen was over two feet above the floor. Maintenance Staff A verified this finding.

(A)
Based on observation and interview, the facility failed maintain all components of the electrical system in accordance with the National Fire Protection Association 70. The location of deficient practice was located in one of thirty-five smoke compartments affecting staff, visitors and residents in that compartment. The facility census was 78 with a capacity of 126.

Findings include:

Obervation and interview on 01/07/14, revealed an open junction box in the corridor with exposed wiring by room #1008. Maintenance Staff A confirmed this observation.

NFPA standard: 1999 NFPA 70



(B)
Kehl Diabetes Center

Based on observation and interview, the facility failed maintain all components of the electrical system in accordance with the National Fire Protection Association 70. The location of deficient practice was located in one of one smoke compartments affecting occupants in that compartment. The facility is a business occupancy.

Findings include:

Observation and interview on 01/08/14, revealed a missing face plate for an outlet in the Electrical room of the Kehl Diabetes Center. Maintenance Staff A confirmed this observation.

NFPA standard: 1999 NFPA 70

Based on observation and staff interview, the facility failed to maintain the lay-in tile ceiling in two areas. The fire-rated ceiling tile assembly had been altered reducing the construction type to an unprotected non-combustible. This deficient practice affects two of five smoke compartments on the first floor and all staff and visitors in those compartments. This facility has a capacity of 124 and a census of 78 residents.

Findings include:

Observation and staff interview on 01/06/14, revealed the following deficiencies with the lay-in tile ceiling:
1. There was a two inch hole in the ceiling tile by the West exit of the Maintenance Shop #1371.
2. There was a two inch hole in the ceiling tile by the Catering dishes in the Kitchen.

Maintenance Staff A confirmed these observations during the survey process.

Based on observation and interview, this facility is not assuring that seven smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects all occupants of the building, including staff, visitors and residents in fourteen of thirty-five smoke zones. This facility has a capacity of 126 with a census of 78 residents.

Findings include:

Observation and staff interview on 01/06-07/14, revealed the following deficiencies with smoke barriers:
1. There was a one inch penetration around blue wiring in the smoke barrier by stairwell #5 on the 1st floor.
2. There was a 1/2 inch penetration around blue wiring in the smoke barrier adjacent from room #1030.
3. There was a 1/2 inch penetration in the smoke barrier by room #1606.
4. There was an open 3 inch conduit in the smoke barrier by stairwell #5 on the 4th floor.
5. There was an open 4 inch conduit in the smoke barrier from the hospital to the vestibule for the Wendt Cancer Center.
6. There was an open conduit in the smoke barrier by room #2012.
7. There was an open 4 inch conduit in the smoke barrier from the Wendt Cancer Center to the vestibule for the Hospital.
According to the facility layout, these are required barriers. Maintenance Staff A confirmed these observations.

NFPA standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

Based on observation and interview, the facility failed to maintain smoke doors to close and resist the passage of smoke. The smoke doors affected four of the thirty-five smoke compartments in the building. The facility has 126 certified beds and at the time of the survey the census was 78.

Findings include:

Observation and interview on 01/07/14, revealed the following smoke door deficiencies:
1. The elevator lobby doors by room #4411 did not close and latch into the frame properly.
2. The 3rd floor elevator lobby doors for Elevator E F did not latch into the frame properly.
3. The smoke doors by room #3346, south leaf, did not close completely.
Maintenance Staff A confirmed these observations during the survey process.

NFPA standard: Requires doors in smoke barriers to be self-closing and resist the passage of smoke, 2000 NFPA 101, 19.3.7.6

Based on observation and interview, the facility failed to provide separation of one hazardous area from other compartments. The area of deficient practice affected one of eight smoke compartments on the third floor. This facility has a capacity of 126 and a census of 78 residents.

Findings include:

Observation and interview on 01/07/14, revealed the door to Soiled Linen room #3415 did not latch into the frame. Maintenance Staff A confirmed these observations.

Hazardous area with Sprinkler
NFPA standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have closers and positive latches. 2000 NFPA 101, 19.3.2.1

Based on observation and interview, the facility is not providing exiting out of one area without special knowledge of the doors locking device. This deficient practice affects all occupants including staff, visitors and residents, in the Emergency Room. The facility has a capacity of 126 and a census of 78 residents.

Findings include:

Observation and interview on 01/07/14, revealed the Main door and exit door by room #2012 for the Emergency Room did not release the mag lock when the panic bar was activated. The doors would release when a button on the wall was pushed, however, there was not any indication to push the button for exiting. Maintenance Staff A said the magnetic locks were installed for security purposes to the Emergency Room.

NFPA standard: 2000 NFPA 101, 19.

Based on record review and interview, the facility failed to document the emergency egress lighting monthly, documentation was dated only from September 2013. This deficient practice affects thirty-five of thirty-five smoke compartments and all occupants of the facility. This facility has a capacity of 126 and a census of 78 residents.

Findings include:

Observation of the facility's maintenance records and staff interview on 01/06/14, revealed the absence of documentation regarding the testing of the emergency battery lighting system. According to Maintenance Staff A, the lights were tested monthly, but there was no documentation to show that the monthly tests were conducted before September 2013.

NFPA standard: Requires a documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours. 2000 NFPA 101, 7.9.3



Finley Hospital Therapy Services


Based on record review and interview, the facility failed to test and document the emergency egress lighting monthly and annually. This deficient practice affects one of one compartments and all occupants of the facility. This facility is business occupancy.

Findings include:

Observation of the facility's maintenance records and interview on 01/08/14, revealed the absence of documentation regarding the testing of the emergency battery lighting system. According to Administrative Staff A, the emergency egress lighting had not been tested monthly for 30 seconds nor an annual test for 90 minutes under load been performed.


NFPA standard: Requires a documented monthly test of battery-powered emergency lighting for at least 30 seconds, and an annual test for a duration of 1-1/2 hours. 2000 NFPA 101, 7.9.3

Kehl Diabetes/Babka Wellness

Based on observation and interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff and visitors. This facility is business occupancy.

Findings include:

Observation and interview on 01/08/14, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the Electrical room, electrical breaker #53 was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by the deficient practice. Maintenance Staff verified this observation.

Based on observation and record review, the facility failed to provide a properly tested and maintained fire alarm system. All of the facilities were directly affected by the deficient practice. The facilities were business occupancy.

Findings include:

A review of the inspection records for the fire alarm system on 01/08/14, revealed Finley Rehab Westmark/Pedeatrics Rehab and Kehl Diabetes/Babka Wellness did not have documentation from current fire alarm inspections. Maintenance Staff A confirmed observations during the survey process.

NFPA standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per the 1999 edition of NFPA 72, table 7-3.2. and listed as required by NFPA 72, 7-5.2.2

Based on observation and interview, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of National Fire Protection Association (NFPA) 25, and the 1999 edition of National Fire Protection Association (NFPA) 13. This can affect the operation of the heads by obstructing spray patterns, delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants in three smoke zones at risk in the event of a fire. The census was 78 with a capacity of 126.

Findings include:

Observation and interview on 01/06-08/14, revealed the following deficiencies with the sprinkler system:
1. A missing escutcheon plate for a sprinkler head in the middle of the Maintenance Shop #1371.
2. A missing escutcheon plate for the sprinkler head by the Kitchen door #1508 in the corridor.
3. Eight missing escutcheon plates for sprinkler heads located in the West exit path of the Finley Hospital Therapy Services Building.
4. One sprinkler head with paint of the fusible link in the West exit path of the Finley Hospital Therapy Services Building.

These observations were verified with Maintenance Staff A.


-NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1

NFPA Standard: The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 1-4.4

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. NFPA 25, 2-2.1.1

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water-filled piping is installed; and replacing worn or missing fire hose or nozzles. NFPA 25, 1-11.3

NFPA Standard: Unacceptable obstructions to spray patterns shall be corrected. 1998 NFPA 25, 2-2.1.2

Finley Rehab Westmark/Pedeatric Rehab

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Assocation 25. This deficient practice affects all occupants in the facility. The facility is business occupancy.

Findings include:

Observation and interview on 01/08/14, revealed the facility did not have documentation of a current sprinker inspection. The last inspection according to the tag on the system was 2009. Maintenance Staff A verified this finding.


NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1

Finley Hospital Therapy Services

Based on observation and interview, the facility failed to maintain and test fire extinguishers as required. The deficient practice could affect staff and visitors in the facility. The facility is business occupancy.

Findings include:

Observation and interview on 01/08/14, revealed all of the fire extinguishers in the facility were missing monthly inspections. Maintenance Staff A verified these findings.


Actual NFPA standard: Fire extinguishers shall be inspected when placed in service and thereafter at approximately 30-day intervals per 1998 NFPA 10, 4-3.1

Babka Wellness


Based on observation and interview, the facility did not maintain one egress path. This deficient practice affects all occupants and visitors. This facility is business occupancy.

Findings include:

Observation and interview on 01/08/14, revealed three chairs outside of the Fitness room in the exit corridor. These chairs block the exit corridor allowing approximately less than 36 inches clear walkway. Maintenance Staff A verified this finding.

The facility failed to provide draperies and curtains that are in accordance with provisions of National Fire Protection Association (NFPA) 13. This has the potential of affecting all the residents, staff and visitors in two of thirty-five smoke zones. This facility has a capacity of 126 and a census of 78 residents.

Findings include:

Observation and interview on 01/07/14, revealed the following areas had curtains with less than 1/2 inch mesh on the top of the curtains:
1. Rooms #524, #523, #522.
2. Entire Acute Rehab wing.
Maintenance Staff A confirmed these observations.

NFPA Standard: Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations in health care occupancies are in accordance with the provisions of 10.3.1 and NFPA 13, Standards for the Installation of Sprinkler Systems. 2000 NFPA 13

Based on observation and interview, the facility failed to maintain the relief valve height from the floor of one water heater. This deficient practice affects all occupants in the Kitchen. The facility has a capacity of 126 and the census of 78 residents.

Finding include:

Observation and interview on 1/06/14, revealed the relief valve pipe for the water heater in the Kitchen was over two feet above the floor. Maintenance Staff A verified this finding.

(A)
Based on observation and interview, the facility failed maintain all components of the electrical system in accordance with the National Fire Protection Association 70. The location of deficient practice was located in one of thirty-five smoke compartments affecting staff, visitors and residents in that compartment. The facility census was 78 with a capacity of 126.

Findings include:

Obervation and interview on 01/07/14, revealed an open junction box in the corridor with exposed wiring by room #1008. Maintenance Staff A confirmed this observation.

NFPA standard: 1999 NFPA 70



(B)
Kehl Diabetes Center

Based on observation and interview, the facility failed maintain all components of the electrical system in accordance with the National Fire Protection Association 70. The location of deficient practice was located in one of one smoke compartments affecting occupants in that compartment. The facility is a business occupancy.

Findings include:

Observation and interview on 01/08/14, revealed a missing face plate for an outlet in the Electrical room of the Kehl Diabetes Center. Maintenance Staff A confirmed this observation.

NFPA standard: 1999 NFPA 70