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The facility did not ensure that vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour as required by the referenced LSC.

On 10/24/16 at 10:30 AM and times throughout the day, the surveyor and engineering technician observed that floors in the telecom closets in building 3 had floor to floor voids and penetrations that were not sealed using a UL approved system for fire stopping two (2) hour enclosures.

The facility did not ensure that hazardous areas were either separated by construction providing at least a one hour fire resistance rating or protected by an automatic extinguishing system, where the sprinkler option is used the areas shall be separated by smoke resisting partitions and self-closing doors as required by 19.3.2.1

On 10/24/-10/28/16 at 10:30 AM and times throughout the dates of survey, the surveyor along with an engineering technician observed that storage rooms, machine rooms, and soiled utility closets throughout the facility lacked door closers and were lay in ceilings were absent voids and penetrations were not sealed with materials listed to resist the passage of smoke and fire.

The facility did not ensure that emergency lighting of at least 1½-hour duration is provided in accordance with LSC 7.9 & 19.2.9.1.

On 10/24/-10/28/16 at 10:30 AM and times throughout the dates of survey, the surveyor was not provided with documentation by the Director of Facilities to indicate that all the battery backup emergency lights were tested for 30 seconds a month and 90 minutes annually to include all off site services as required.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition as required by NFPA 101, NFPA 13 " Standard for the Installation of Sprinkler Systems " , and section 9.7.5 of NFPA 25, " Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems ";
On 10/25 & 10/28/16 at 10:00 and times throughout the day, the surveyor was not provided with documentation to indicate that the sprinkler system had had an internal obstruction testing as required by NFPA 25 " Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems " last check 02/25/11 and that the dry pendant sprinklers in the walk-in coolers and freezers had not been replaced and/or tested every 10 years as required dated 2003.

1. The facility did not ensure that the required remote alarm annunciator at a staffed location for the facilities emergency generator as required in NFPA 99 " Health Care Facilities " Section 3-4.1.1.15(a) and (b) and as part of the facilities preventive maintenance program.

On 07/01/14 at 12:15 PM, the surveyor observed along with the Maintenance Director that the facility lacked a remote annunciator for the facilities emergency generator at a staffed location as required in NFPA 99 " Health Care Facilities " Section 3-4.1.1.15(a) and (b).
2. The facility did not ensure that electrical receptacle outlets in patient areas were maintained as required in NFPA 99 " Health Care Facilities " Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program..

On 10/26 & 10/28/16 at 10:00 AM, the surveyor was not provided with documentation by the Director of Facilities that electrical receptacle outlets in patient areas for the facility offsite patient treatment properties were inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3. , and as part of the facilities preventive maintenance program.

The facility did not ensure that vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour as required by the referenced LSC.

On 10/24/16 at 10:30 AM and times throughout the day, the surveyor and engineering technician observed that floors in the telecom closets in building 3 had floor to floor voids and penetrations that were not sealed using a UL approved system for fire stopping two (2) hour enclosures.

The facility did not ensure that hazardous areas were either separated by construction providing at least a one hour fire resistance rating or protected by an automatic extinguishing system, where the sprinkler option is used the areas shall be separated by smoke resisting partitions and self-closing doors as required by 19.3.2.1

On 10/24/-10/28/16 at 10:30 AM and times throughout the dates of survey, the surveyor along with an engineering technician observed that storage rooms, machine rooms, and soiled utility closets throughout the facility lacked door closers and were lay in ceilings were absent voids and penetrations were not sealed with materials listed to resist the passage of smoke and fire.

The facility did not ensure that emergency lighting of at least 1½-hour duration is provided in accordance with LSC 7.9 & 19.2.9.1.

On 10/24/-10/28/16 at 10:30 AM and times throughout the dates of survey, the surveyor was not provided with documentation by the Director of Facilities to indicate that all the battery backup emergency lights were tested for 30 seconds a month and 90 minutes annually to include all off site services as required.

The facility did not ensure that a fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72.

On 10/26/16 & 10/28/16 at 11:30 PM, the surveyor was not provided with documentation that the fire alarm was tested semiannually. The test dates provided were 07/22/16 & 04/21/16 identifying that the fire alarm contractor was approximately 90 days late & documentation was not available for Rehab Dynamics II off site to indicate the fire alarm had been tested. Documentation of sensitivity testing was not available for 420 North Main and 975 Farmington off sites.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition as required by NFPA 101, NFPA 13 " Standard for the Installation of Sprinkler Systems " , and section 9.7.5 of NFPA 25, " Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems ";
On 10/25 & 10/28/16 at 10:00 and times throughout the day, the surveyor was not provided with documentation to indicate that the sprinkler system had had an internal obstruction testing as required by NFPA 25 " Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems " last check 02/25/11 and that the dry pendant sprinklers in the walk-in coolers and freezers had not been replaced and/or tested every 10 years as required dated 2003.

1. The facility did not ensure that the required remote alarm annunciator at a staffed location for the facilities emergency generator as required in NFPA 99 " Health Care Facilities " Section 3-4.1.1.15(a) and (b) and as part of the facilities preventive maintenance program.

On 07/01/14 at 12:15 PM, the surveyor observed along with the Maintenance Director that the facility lacked a remote annunciator for the facilities emergency generator at a staffed location as required in NFPA 99 " Health Care Facilities " Section 3-4.1.1.15(a) and (b).
2. The facility did not ensure that electrical receptacle outlets in patient areas were maintained as required in NFPA 99 " Health Care Facilities " Section 3-3.3.3 and 3-3.4.2.3, and as part of the facilities preventive maintenance program..

On 10/26 & 10/28/16 at 10:00 AM, the surveyor was not provided with documentation by the Director of Facilities that electrical receptacle outlets in patient areas for the facility offsite patient treatment properties were inspected annually as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3. , and as part of the facilities preventive maintenance program.