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Based on observation, interview, and record review, the facility failed to ensure the walking surfaces of 5 of 5 patio areas designated as exits were a hard packed all-weather travel surface to the public way.

Findings include:

1) The facility's document titled Evacuation Route, indicated the following:

a) The designated exits located in Pod 100 & Pod 200, and the exit doors located in the corridors outside of Pod 100 & Pod 200, directed traffic to the West patio area.

b) Pod 300 contained a designated exit directing traffic into the Designated Smoking patio area.

c) The main corridor dividing Side A & Side B contained three designated exit doors directing traffic to the Main patio area.

d) Pod 400 contained a designated exit directing traffic into the Pod 400 patio area.

e) The designated exits located in Pod 500 & Pod 600, and the exit doors located in the corridors outside of Pod 500 & 600, directed traffic to the East patio area.

2) On 12/19/19 and 12/20/19, during the tour of the facility, the condition of the exit discharge from the patio to the public way was noted as follows:

a) The West exit discharge to the public way was noted to contain 4" rocks.

b) The Designated Smoking patio exit discharge to the public way was noted to contain 4 steps and rocks.

c) The Main patio area exit discharge to the public way was noted to contain 3 steps and rocks.

d) The Pod 400 patio exit discharge to the public way was noted to contain 5 steps and rocks.

e) The East patio exit discharge to the public way was noted to contain 4" rocks.

These observations were made in the presence of the Maintenance Director.

National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems,(2010 Edition)

6.2.7 Escutcheons and Cover Plates.
6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.
6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly.
6.2.7.3 Cover plates used with concealed sprinklers shall be part of the listed sprinkler assembly.
6.2.8 Guards. Sprinklers subject to mechanical injury shall be protected with listed guards.

26.1* General
A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, (2011 Edition)

14.2 Internal Inspection of Piping (5-year Obstruction Tests)
14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.


Based on observation, interview and document review, the facility failed to maintain the automatic fire sprinkler system in accordance with National Fire Protection Association 13, Standard for the Installation of Sprinkler Systems, and National Fire Protection Association, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Findings include:

1) On 12/18/19, a review of the facility's Report of Inspection for the fire sprinkler system, dated 7/3/19, indicated "NO" for "Are fire dept. Connections in satisfactory condition, couplings free, caps or plugs in place and check valves tight?". A Report of Inspection, dated 10/2/19, again documented the fire department connections as not in satisfactory condition. On 12/19/19, in the morning, the Maintenance Director explained the facility was aware of the deficiency, and provided an email, dated 7/5/19, with an attached proposal for a fire department connection and drain repair, sent to the facility's Chief Executive Officer. The Director explained that because the proposal was for $3,765.00, the facility had forwarded the proposal to the Corporation for approval, but had not received a response yet. On 12/19/19, during a tour of the facility, the Fire Department Connection located outside the Riser Room, was tagged "Deficient", and the tag was noted to be dated 9/2/18.

2) On 12/18/19, a review of the facility's fire sprinkler system inspection was conducted. The Maintenance Director verified on 12/19/19, no documentation of an Internal Inspection of Piping (5-year obstruction test) could be located. The Director explained the facility had more than one sprinkler system vendor in the last few years.

3) On 12/19/19 during a tour of the facility, sprinklers in the following locations were noted to be missing escutcheons to cover the annular space or had a gap between the ceiling and the sprinklers:

a) Patient Room #105

b) Patient Room #107

c) Patient Room #102

d) Patient Room #110

4) On 12/20/19 during a tour of the facility's kitchen, the sprinklers in the walk-in refrigerator and walk-in freezer were observed to not be protected by cages.

These observations were made in the presence of the Maintenance Director.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition

110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operations and maintenance of such equipment.
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26 (A)(1), (A)(2), and (A)(3) or as required or permitted elsewhere in this Code.

(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26 (A)(1) unless the requirements of 110.26 (A)(1)(a), (A)(1)(b), or (A)(1)(c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed. (Nominal Voltage to Ground of 0 -150 = 3 feet).


Based on observation, the facility failed to ensure electrical panels had the required depth of working space.

Findings include:

On 12/19/19, during a tour of the facility, the following electrical panels were observed to be obstructed:

- Panel EDH, in the Electric Room, located in the loading zone corridor, was obstructed by a cart
- Panels EA & LH in the Electric room on A side, was obstructed by a ladder and a box
- Panel LCBA in the Housekeeping Director's office, was obstructed by a desk

These observations were made in the presence of the Maintenance Director.

NOTE: NFPA 101, 2012 Edition defines patient-care related electrical equipment as, "Electrical equipment appliance that is intended to be used for diagnostic, therapeutic, or monitoring purposes in a patient care vicinity."

Based on interview, the facility failed to provide documentation that all fixed and portable patient-care related electrical equipment had been tested.

Findings include:

On 12/19/19, the Maintenance Director explained patient-care related electrical equipment was tested annually and the equipment was tagged. On 12/19/19 and 12/20/19, during a tour of the facility, the following items were not tagged as tested, or the tags were expired:

- On 12/19/19, in the common area of Pod 100, a Dinamap V100, portable vital signs monitor displayed an equipment tag that expired in November, 2019.

- On 12/19/19, in the common area of Pod 100, a Horizon 62E Centrifuge was observed not to have a tag indicating the equipment had been tested.

- On 12/19/19, in Patient Room #218, a suction unit displayed an equipment tag that expired in August, 2019.

- On 12/19/19, in Patient Room #218, an Enteralite Infinity Tube Feeding Pump, was observed not to have a tag indicating the equipment had been tested.

- On 12/19/19, in Patient Room #220, a Medline Nebulizer was observed not to have a tag indicating the equipment had been tested.

- On 12/20/19, in Patient Room #401, an Enteralite Infinity Tube Feeding Pump, was observed not to have a tag indicating the equipment had been tested.

- On 12/20/19, in the common area of Pod 400, a Vario suction unit displayed an equipment tag that expired in August, 2019.

The Maintenance Director acknowledged the deficiencies upon discovery.