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K-321 Based upon observations made in the presence of the plant manager on 05/02/2017, 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.

Findings include:

During the facility tour the materials management storage room and the main floor nursing storage rooms were observed to not have self-closing devices on the doors. The doors shall be self-closing or automatic-closing in accordance with NFPA 101 19.3.2.1.3.

Based upon record review made in the presence of the plant manager on 05/02/2017, 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.

Findings include:

During the record review the facility failed to provide documentation of the annual smoke and heat detector test. Smoke and heat detectors shall be inspected annually in accordance with NFPA 72 table 14.4.5. (j

Based upon record review made in the presence of the plant manager on 05/02/2017, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 101 19.3.5.1, 9.7.5.

Findings include:

The facility failed to provide documentation of a current annual sprinkler system test, a tag on the riser indicated that the last test was in 2015 the plant manager confirmed this finding. Sprinkler systems shall be tested annually in accordance with NFPA 25 table 5.1.1.2.

Based upon observations made in the presence of the administrator and the plant manager on 05/02/2017, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

Findings include:

During the facility tour It was observed that the electrical service panels located in the radiology hallway accessible by the public were unlocked allowing unauthorized access to unqualified persons. Ref: NFPA 70,110-31

Based upon observations made during the record review with the plant manager on 05/02/2017, it was determined that the facility did not provide a written fire safety plan in accordance with NFPA 10119.7.2.2.

Findings include:

During the record review it was observed that the facility failed to provide a written documentation for the fire safety plan that included all nine objectives, evacuation of the smoke compartment was not observed to be in the policy. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire.
In accordance with NFPA 19.7.2.2

Based upon record review made in the presence of the administrator and the plant manager on 05/02/2017, it was determined that the facility did not maintain, inspect and exercise the facilities emergency generator set in accordance with NFPA 99 6.4.4 and NFPA 110 8.4.2.3.

Findings include:

During the facility tour it was observed that neither of the two generators had a remote manual stop located outside of the enclosure. All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building in accordance with NFPA 99 6.5.4 and NFPA 110 5.6.5.6.