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Based upon record review made in the presence of the plant manager on 06-18-2019, it was determined that the facility did not maintain the fire alarm system, Device test results (alarm initiating, supervisory alarm initiating, and notification) are required to be itemized list with the following information, device type, address, location, and test result as required. In accordance with Ref: 2012 NFPA 101 Section 19.3.4.1, 9.6.1.5; 2010 NFPA 72 Table 14.4.5 Item 20; Ref: 2012 NFPA 101 Section 19.3.4.1, 9.6.1.5; 2010 NFPA 72 Section 14.6.2.4, Figure 14.6.2.4 Section 7.12-7.14 and page 11 of 11)

This deficiency affected 1 fire wall.

Findings include:
1- During the record review the facility failed to provide documentation that the fire alarm control panel batteries had been tested under load two times in the last year. Batteries need to be tested semiannually in accordance with NFPA 101 20.3.4.1. & 9.6.1.1.; and NFPA 72 Table 14.4.5

Based upon observations made in the presence of the plant manager on 06-18-2019, 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 2 of several GFIC outlets and two of several electrical panels.

Findings include
1-During the facility tour it was observed that there was 4 red outlets in the med surge break room by the hand wash sink were not GFIC protected and were observed to be within 6ft of the sink. 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. In accordance with 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 there was a normal power outlet in med surge by patient room #9 that was not GFIC protected and were observed to be within 6ft of the sink. 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. In accordance with 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 electrical panel in the data closet in the radiology department were observed to be blocked by a data rack that was floor mounted within 18 inches of the face of the panel. Service panels are to have a clear working space of 36" maintained in front of them at all times. In accordance with NFPA 101 19.5.1, 9.1.2., NFPA 70, 110-26 (a)
4- During the facility tour it was observed that the electrical panel in the radiology department data closet did not have a breaker legend in accordance with NFPA 101 19.5.1, 9.1.2., NFPA 70 110.22

Based upon made in the presence of the plant manager on 06-18-2019, 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 record review made in the presence of the plant manager on 06-18-2019, 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.

This deficiency affected one of the required tests.

Findings include:
1-During the record review the facility failed to provide documentation that the Maintenance of the generator batteries had been conducted. Maintenance of Lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted in accordance with NFPA 110 8.3, 8.3.7