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Referenced code: Title 42 CFR 485.623(a)

Based on observation and interview, it was determined the facility failed to maintain the fire and smoke rated barrier in one (above the fire-rated doors near the Chapel, Room C100) of six areas observed by protecting penetrations in the barrier with a system or material capable of limiting the transfer of smoke. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that smoke would not spread from one side of the barrier to the other in the event of a fire and smoke event. Findings follow:

A. While touring the facility with the Senior Maintenance Mechanic on 05/10/2017 at 1330, one penetration in the fire-rated barrier above the fire-rated doors near the Chapel was not sealed with a system or material capable of limiting the transfer of smoke from one side of the barrier to the other.
B. During the tour, the Senior Maintenance Mechanic verified the penetration was not sealed with a material capable of limiting the transfer of smoke from one side of the barriers to the other.

Referenced code: NFPA 101; 2012 edition, Section 8.4.4.1

Based on interview with the Maintenance Supervisor, there was no evidence the required 4-hour load test had been performed on the Essential Electrical System (EES-emergency generator and all ancillary equipment) within the previous 36 months. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured the EES would function as required during a loss of utility supplied power. Findings follow:

A. Review of the emergency generator maintenance logs on 05/09/2017 at 0900 revealed there was no evidence to verify the required 4-hour load test had been performed on the EES for the prior 36 months.
B. During an interview with the Engineering Department Manager on 05/09/2017 at 0900, it was verified the required test had not been performed within the prior 36 month period.

Referenced Code: NFPA 99 (2012 edition), Section: 6.4.4; NFPA 110 (2010 edition), Section: 8.4.9

Based on observation and interview, it was observed the electrical equipment in two (electrical cage in the boiler room and the room for Air Handler #6) of six areas observed did not have a minimum of 36 inches (three feet) working space in front of the equipment because of items stored in these areas. The failed practice had the potential to affect all patients, visitors, and staff because rapid access to the panels could not be gained in the event of an emergency. Findings follow:

A. While touring the facility on 05/10/2017 at 0940, it was observed a door leaning against an electrical switchboard in electrical cage inside the boiler room.
B. While touring the facility on 05/10/2017 at 0955, it was observed negative air machines in front of two electrical panels in the room for Air Handler #6.
C. During the tour, the Senior Maintenance Mechanic verified the equipment did not have the required clearance.


Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment in accordance with NFPA 70 (Nation Electric Code) in two (above the drop down ceiling near the Mail Room and on the wall of the first floor Communications Room) of twelve areas observed by not maintaining covers on electrical boxes. The failed practice had the potential to affect all patients, visitors, and staff because uncovered electrical boxes are a potential fire hazard. Findings follow:

A. While touring the facility on 05/10/2017 at 0945, it was observed an electrical box did not have a cover and electrical wires were exposed on the wall in the first floor Communications Room (165).
B. While touring the facility on 05/10/2017 at 1330, it was observed an electrical box did not have a cover and electrical wires were exposed above the drop down ceiling near the Mail Room (B114).
C. During the tour, the Senior Maintenance Mechanic verified the electrical boxes did not have covers.

Referenced Code: NFPA 99 (2012 edition), Section: 15.5.1.2; NFPA 70 (2011 edition), Sections: 110.26, 314.28 (C)