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K-223 Based on observations made in the presence of the plant manager on 07-31-2018, it was determined that the facility did not maintain doors with self-closing devices in accordance with NFPA 19.2.2.2.8

This deficiency affected 3 of 4 smoke compartments.

Findings include:
1-During the facility tour it was observed that the rated corridor access doors entering the medical surgical areas had the positive latching device removed preventing the doors from being in the latched position in accordance with NFPA 101 19.2.2.2.7, 19.2.2.2.8, 7.2.1.15
2- During the facility tour it was observed that the access door into the clean holding room in the women's center holding door did not close to a full latched position in accordance with 19.2.2.2.7, 19.2.2.2.8
3- During the facility tour it was observed that the rated access door into the house keeping closet did not close to the latched position in accordance with 19.2.2.2.7, 19.2.2.2.8
4- During the facility tour it was observed that the double corridor doors leading back to the medical surgical unit did not close or latch during the fire drill because of pressure from the smoke control system and not in accordance with NFPA 101 19.2.2.2.7, 19.2.2.2.8, 7.2.1.15

Based upon observations/record review made in the presence of the plant manager on 07/31/2018, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 101, 9.7.5.

This deficiency affected 1 of 4 smoke compartments.

Findings include:
1- The fire sprinkler head assembly located in the west housekeeping in the medical surgical department closet had storage to close to the sprinkler head and not in accordance with NFPA 13 8.5.5.2.1,8.5.5.3
2- The fire sprinkler head assembly located in the housekeeping in the medical surgical department closet had storage to close to the sprinkler head and not in accordance with NFPA 13 8.5.5.2.1, 8.5.5.3

K-521 Based upon observations made in the presence of the plant manager on 07-31-2018, 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.

The deficiency affected 4 of 4 smoke compartments

Findings include


During the record review the facility failed to provide an itemized list of smoke damper locations and the tests that were performed. All inspections and testing shall be documented, indicating the location of the fire damper, date(s) of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected in accordance with NFPA 80 19.3.4.

Based on observations made in the presences of the plant manager on 07-31-2018, it was determined that the facility did not test or maintain the Engineered smoke control system in accordance with NFPA 101 19.7.7

The deficiency affected 1 of 4 smoke compartments

Findings include
During the facility tour it was discovered that the facility had an Engineered smoke control system that was not tested prior to or at the time of this survey and not in accordance with NFPA 101 19.7.7

K-914. Based upon observations made in the presence of the plant manager on 07-31-2018, it was determined that the facility did not test the Line Isolation Monitors in accordance with NFPA 99 6.3.4.1.4, 6.3.3.3.2

The deficiency affected all line isolation monitors.

Findings include:
1-During the document review it discovered that there was no tests being performed on the LIM circuits.LIM shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6).
For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. And not in accordance with NFPA 99 6.3.4.1.4

K-918 Based upon record review made in the presence of the plant manager on 07-31-2018, it was determined that the facility did not maintain, inspect and exercise the facilities emergency generator set in accordance with NFPA 19.5.1, NFPA 99 6.4.4.1.3 and NFPA 110 8.3.7.1

This deficiency affected 1 of the several generator maintenance tests required.

Findings include:
The required monthly testing and recording of electrolyte specific gravity or conductance results (CCA) of the lead acid batteries in connection with the emergency power supply system (generator) were not completed as required.

K-920. Based upon observations made in the presence of the plant manager on 07-31-2018, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 19.5.1

The deficiency affected 3 of several outlets

Findings include:

1-During the facility tour it observed that there was 2 daisy chained plug strips plugged in the Laboratory.. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling in accordance with NFPA 19.5.1, 70 110-3b, 99 10.2.3.6
2--During the facility tour it observed that there was 2 daisy chained plug strips plugged in the ultra sound nurse's station. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling in accordance with NFPA 19.5.1, 70 110-3b, 99 10.2.3.6