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Based upon observations made in the presence of the plant manager on 01-15-2019, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1, 19.3.2.1.1 through 19.3.2.1.5(18.3.2.1)

This deficiency affected 4 of several smoke compartments

Findings include:
1- During the facility tour it was observed that in the penthouse mechanical room there was 3 unsealed penetrations, Hazardous areas shall be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1.
2- During the facility tour it was observed that in the mechanical room the 1 hour fire wall by the kitchen area had unsealed penetrations, Hazardous areas shall be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1.
3- During the facility tour it was observed that in the dietary storage room door was propped open. Hazardous areas shall be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1.

Based upon record review made in the presence of the plant manager on 01-15-2019, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 101 9.6.1.3, 9.6.1.5.; and NFPA 72.

This deficiency affected 1 of 2 tests.

Findings include:
During the record review portion of the survey the facility documentation of two riser tamper switch tests were not completed on schedule. Valve supervisory alarm devices shall be tested semiannually in accordance with NFPA 101 19.3.5.1, 9.7.5. And NFPA 72 table 14.4.5. (15.l-1)

Based upon observations made in the presence of the plant manager on 01-15-2019, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 101 19.3.5.1.

This deficiency affected 1 of several sprinkler heads.

Findings include:
1. The fire sprinkler head located in the electrical room by pre op has paint and or corrosion on the body of the sprinkler head that could affect the proper function of the sprinkler in accordance with NFPA 101 19.3.5.1; 9.7.5 and NFPA 25

Based upon observations made in the presence of the plant manager on 01-15-2019, it was determined that the facility did not maintain the fire resistance rating in accordance with NFPA 101 19.3.7., 8.5.3

The deficiency affected 1 of several fire/smoke compartments.

Findings include:
1-During the tour of the facility it was observed that the Fire barrier wall above the fire doors on the 3rd floor corridor by room 304 had unsealed penetrations and not in accordance with NFPA 101 19.3.7.3, 8.5.

Based upon observations made in the presence of the plant manager on 01-15-2019, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

This deficiency affected 7 of several GFIC outlets.

Findings include
1-During the facility tour it was observed that the 2 outlet's in the 3rd floor elevator lobby were not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
2- During the facility tour it was observed that the outlet in the soiled holding room was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
3-During the facility tour it was observed that the 2 outlet's in the 2nd floor elevator lobby were not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
4- During the facility tour it was observed that the outlet in the house keeping closet by the radiologist reading room were not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
5- During the facility tour it was observed that the outlet in the ultra sound room was not GFIC protected and were observed to be within 6ft of the sink and not GFCI protected. The plant manager confirmed these findings. GFCI outlets are required where the receptacles are installed to serve the countertop surfaces and are located within 6 ft. (1.83 m) of the outside edge of the sink. NFPA 101 Section 19.5.1, 9.1.2; 1999 NFPA 70 Article 210-8(7)
6- During the facility tour it was observed that the some of the electrical panels thru out the facility did not have a current circuit directory or circuit identification.

Based upon made in the presence of the plant manager on 01-15-2019, it was determined that the facility did not install or maintain the buildings heating, ventilating and air conditioning systems in accordance with NFPA 101 19.5.2.1 and 9.2.

This deficiency affected all smoke dampers.

Findings include:
1-During the record review the facility failed to provide the testing documentation that the (Emergency control functions) smoke damper operations had been tested annually with the initiating device that activates the damper and not in accordance with NFPA 19.5.2.1, 9.2 and NFPA 72 Table 14.4.2.2

Based upon observations made during the record review in the presence of the plant manager and on 01-15-2019, it was determined that the facility did not have current elevator certificates in accordance with 19.5.3, 9.4.2, 9.4.3.

This deficiency affected all elevators.

Findings include: During the record review the facility failed to supply an updated elevator certificate. This finding was confirmed and the facility called and set up the inspection for certification the day of this survey.