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Based on observation, record review and interview, the facility failed to develop, at a minimum, policies and procedures that address; the provision of subsistence needs for staff and patients whether they evacuate or shelter in place, including, but not limited to: Food, water, medical and pharmaceutical supplies, alternate sources of energy to maintain temperatures to protect patient health and safety and for the safe and sanitary storage of provisions, emergency lighting, fire detection, extinguishing and alarm systems, and sewage and waste disposal. This deficient practice could affect all occupants in the event of a facility wide emergency or disaster.

Findings Include:
A) On April 14, 2021, at approximately 1:00 PM, record review of the facility's Emergency Preparedness Plan dated May, 1, 2017, revealed the facility failed to indicate the amount of emergency food and water that would be required for both the patient's and staff during a shelter in place emergency at the facility. Observation on April 14, 2021, 2:30 PM, in the kitchen pantry revealed no food was identified as available in case of emergency and only 36 gallons of potable water were on hand at the time of this survey. Record review of the facility's Shelter in Place policy dated May 1, 2017, found no dietary menu or amount of food or water that would be needed during the shelter in place emergency.

The Director of Facilities and Director of Quality and Compliance confirmed these findings during the exit interview and at the time of observation.

Based on record review and interview, the facility failed to establish the role of the facility under a Waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. This deficient practice could affect all of the occupants in the event of a facility wide disaster.

Findings Include:
On April 14, 2021, at approximately 2:00 PM, record review of the facility's Emergency Preparedness Plan dated May 1, 2017, revealed the facility failed to verify the facility has policies and procedures in it's emergency plan describing the facility's role in providing care and treatment at alternate care sites under an 1135 wavier.

The Director of Facilities and Director of Quality and Compliance confirmed these findings during the exit interview and at the time of observation.

Based on record review and interview, the facility failed to provide initial training in emergency preparedness policies and procedures to all new and exiting staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. This deficient practice could affect all occupants in the event of a facility wide disaster or emergency.

Findings Include:
On April 14, 2021, at approximately 2:00 PM, record review of the facility's Emergency Preparedness Plan dated May 1, 2017, revealed the facility failed to provide a written training program or documentation of implementation of the facility's emergency preparedness policies dated February 22, 2021.

The Director of Facilities and Director of Quality and Compliance confirmed these findings during the exit interview and at the time of record review.

Based on observation and interview, the facility failed to ensure doors in a required means of egress are not equipped with a latch or lock that requires the use of a tool or key from the egress side unless meeting the special locking arrangements for clinical needs in accordance with 19.2.2.2.5.1 and 19.2.2.2.6, special needs locking arrangements in accordance with 19.2.2.2.5.2. This deficient practice could affect 25 occupants in the event of an emergency evacuation.

Findings Include:

1. On April 13, 2021, at approximately 12:00 PM, observation and interview revealed staff on the 4th Floor South Psychology/Mental Health Ward are not issued keys to provide for the rapid removal of occupants from the locked down unit as required by 2012 NFPA 101, 19.2.2.2.6. At the time of observation two unidentified staff members were interviewed at the nurse station. They were asked if they had their keys for the south stairwell exit doors. Neither staff member had keys and one of them stated they were never given keys to unlock the doors. The Maintenance Director at this time stated he is going to have keys made for all staff to carry. This could potentially trap occupants and staff in the event of an emergency evacuation through the south stairs.

2. On April 14, 2021, at approximately 9:30 AM, observation revealed the sliding main entrance doors into the main lobby and the entrance to urgent care are equipped with a thumb turn deadbolt locking mechanism. The deadbolt, when engaged, could potentially prevent the breakaway open feature from operating during an emergency leaving the door wedged in the closed position.

These findings were confirmed through interview with the maintenance director at the time of discovery.

Based on observation and interview, the facility failed to warn occupants of the dangers associated with special extinguishing systems, as required by 19.3. and 2011 NFPA 12. This deficient practice could affect 25 occupants in the event the total flood Carbon Dioxide (CO2) system is discharged.

Findings Include:

On April 14, 2021 at approximately 12:00 PM observation revealed the Hospital Data Center is protected with a CO2 total flood extinguishing system. The installed system does not have the proper signage as required by 2011 NFPA 12, 4.3.2. The facility failed to install specific warning signs in every protected space 4.3.2.3.1 and at the entrance to every protected space 4.3.2.3.2. This could potentially lead occupants to underestimate the danger of the CO2 system becoming exposed during an activation of the system.

These findings were confirmed through interview with the maintenance director at the time of discovery.

Based on observation and interview, the facility failed to ensure stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings are enclosed with construction having a fire-resistance rating of at least 1 hour as required by 19.3.1.1 through 19.3.1.6. This deficient practice could affect 25 occupants in the event the stairwell is needed to exit or refuge in an emergency.

Findings Include:

On April 13, 2021, at approximately 10:30 AM, observation revealed the 7th floor stairwell 1 1/2 hour fire barrier door leading to the roof level is being held open by a cinder block. This could potentially allow heat, smoke and fire to enter into the vertical stairwell space during an emergency where occupants are seeking egress or refuge.

These findings were confirmed through interview with the maintenance director at the time of discovery.

Based on observation and interview the facility failed to provide Hazardous areas protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke revisiting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. This deficient practice could affect a very limited number of occupants in the event of a fire emergency.

Findings Include:
1st floor.
A. On 4/14/2021, at approximately 10:23 AM, observation revealed storage room 148 contained combustible storage with a self-closing door device disconnected required for the hazard in LSC Section 19.3.2.1.3. The inability of the door to positively latched could allow for the transfer of heat and smoke in the event of a fire.

B. On 4/14/2021, at approximately 10:30 AM, observation revealed storage room 116 contained combustible storage without a self-closing door device required for the hazard in LSC Section 19.3.2.1.3. The inability of the door to positively latch could allow for the transfer of heat and smoke in the event of a fire.

The findings were confirmed by interview with the maintenance director at time of discovery.

Based on observation, record review and interview, the facility failed to ensure a fire alarm system is installed in accordance with NFPA 72, as required by 19.3.4.1, 9.6 and 9.6.1.8. This deficient practice could affect all occupants in the event of a fire or smoke event.

Findings Include:

On April, 13, 2021, at approximately 11:00 AM, observation revealed the newly remodeled area of the 6th floor has smoke detectors within 3 feet of air diffusers. Rooms 650, 669, 675, 682, Group Therapy Room, Staff Lounge and the Conference Room all have detectors within 3 feet of air diffusers exceeding 300 Cubic Feet per Minute (CFM). This will potentially allow smoke to be directed away from the detector delaying activation of the fire alarm system.


41647

6th Floor:
On 4/13/2021, at approximately 11:15 AM, observation revealed clean holding 643 has a smoke detector within 3 feet of an air diffuser exceeding 300 CFM. This will potentially allow smoke to be directed away from the detector delaying activation of the fire alarm system.

The findings were confirmed by interview with the maintenance director at time of discovery.


38040

A) On April 14, 2021, at approximately 11:00 AM, review of the annual Fire Alarm Inspection document dated May 22, 2020 revealed the facility failed to equip the ground floor elevator sprinkler pit valve with electronic tamper monitoring. This was noted in the impairments for the required annual NFPA 72 fire alarm report dated May 22, 2020.

B) On April 14, 2021, at approximately 11:00 AM. review of the annual NFPA 72 fire alarm inspection document dated May 22, 2020, revealed seven (7) pull stations and 103 smoke detectors were not tested during the annual test and remain untested at the time of the survey.

C) On April 14, 2021, at approximately 11:00 AM, review of the annual NFPA 72 fire alarm inspection document dated May 22, 2020, revealed the facility failed to provide documentation of the required 2 year sensitivity testing on the fire alarm smoke detectors.

The Director of Facilities and Director of Quality and Compliance confirmed these findings during the exit interview and at the time of record review.

Based on observation and interview, the facility failed to ensure manual initiation of the fire alarm system is arranged as required by 2012 NFPA 101, 9.6.2.7 and A 9.6.2.7. This deficient practice could affect 25 occupants in the event of fire emergency.

Findings Include:

1. On April 13, 2021, at approximately 12:00 PM, observation and interview revealed the facility staff on the 5th Floor South Psychology Ward are not issued keys that control the manual fire alarm pull stations and access the wall mounted fire extinguisher cabinets in accordance with 2012 NFPA 101, 9.6.2.7 and A 9.6.2.7. During interview with the maintenance director it was discovered staff are not issued keys and could not sound the fire alarm or access fire extinguishers in the event of a Fire. This could delay the notification, suppression and response to a fire emergency.

2. On April 13, 2021, at approximately 1:48 PM, observation and interview revealed the facility staff on the 4th Floor South Psychology Ward are not issued keys that control the manual fire alarm pull stations and access the wall mounted fire extinguisher cabinets in accordance with 2012 NFPA 101, 9.6.2.7 and A 9.6.2.7. During interview with the maintenance director it was discovered staff are not issued keys and could not sound the fire alarm or access fire extinguishers in the event of a Fire. This could delay the notification, suppression and response to a fire emergency.

These findings were confirmed through interviews with the Maintenance Director and Floor Staff at the time of discovery.

Based on record review and interview, the facility failed to ensure when a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction (AHJ) has been notified, and all unprotected areas of the building have been evacuated or an approved Fire Watch is provided until the system is restored as required by 9.6.1.6. This deficient practice could affect all of the occupants in the event of a fire emergency or automatic fire alarm impairment.

Findings Include:
On April 14, 2021, at approximately 3:00 PM. review of the facility's Emergency Preparedness Plan dated May 1, 2017 revealed the facility failed to provide a fire watch policy in the event of a fire alarm system impairment to include the correct phone number to contact the state when a fire watch is required.

The Director of Facilities and Director of Quality and Compliance confirmed these findings during the exit interview and at the time of record review.

Based on observation, record review and interview, the facility failed to ensure hospitals where required by construction type are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13-2010, 8.15.13. This deficient practice could affect all occupants in the event of a fire.

Findings Include:

On April 13, 2021 at approximately 11:00 AM observation revealed the 6th floor South Medical room data closet does not have doors or ceiling tiles in the room. This could potentially allow heat to bypass the wet sprinkler protection system and delay activation in the event of a fire. These findings were confirmed through interview with the maintenance director at the time of discovery.


38040

Based on observation and interview, the facility failed to ensure nursing homes and hospitals where required by construction type are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, as required by 19.3.5.1 through 19.3.5.5, 19.4.2, 19.3.5.10, 9.7 and 9.7.1.1(1). This deficient practice could affect all occupants in the event of a fire emergency.

Findings Include:
On April 14, 2021, at approximately 11:00 AM, observation revealed the facility failed to provide automatic fire protection to the kitchen walk-in coolers.

The Director of Facilities and Director of Quality and Compliance confirmed these findings during the exit interview and at the time of observation.


41647

7th Floor:
A. On 4/13/2021, at approximately 10:20 AM, observation revealed room number 779 had a sprinkler head and escutcheon showing signs of corrosion and oxidation. NFPA 25, 5.2.1.2

6th Floor:
B. On 4/13/2021, at approximately 10:53 AM, observation revealed the janitor closet had a ½ inch gap around the water pipe exposing the space between floors. This would allow smoke and heat to escape slowing the activation of the sprinkler system.

C. On 4/13/2021, at approximately 11:27 AM, observation revealed the traction room #636 had a sprinkler head and escutcheon showing signs of corrosion and oxidation. NFPA 25, 5.2.1.2

4th Floor:
D. On 4/13/2021, at approximately 1:35 PM, observation revealed the janitor closet had a sprinkler head and escutcheon showing signs of corrosion and oxidation. NFPA 25, 5.2.1.2

3rd Floor:
E. On 4/13/2021, at approximately 2:45 PM, observation revealed the janitor closet was missing the sprinkler escutcheon exposing the space between floors. This would allow smoke and heat to escape slowing the activation of the sprinkler system.

1st Floor:
F. On 4/14/2021, at approximately 9:50 AM, observation revealed the pain clinic storage room was missing the sprinkler escutcheon exposing the space between floors. This would allow smoke and heat to escape slowing the activation of the sprinkler system.

G. On 4/14/2021, at approximately 10:18 AM, observation revealed cat scan control room was missing ceiling tile exposing the space between floors. This would allow smoke and heat to escape slowing the activation of the sprinkler system.

H. On 4/14/2021, at approximately 11:10 AM, observation revealed the janitor closet near room 104 was missing the sprinkler escutcheon exposing the space between floors. This would allow smoke and heat to escape slowing the activation of the sprinkler system.

Kitchen:
I. On 4/14/2021, at approximately 12:20 PM, observation revealed in the kitchen/dish washing room had several sprinkler heads showing signs of corrosion and oxidation. NFPA 25, 5.2.1.2

The findings were confirmed by interview with the maintenance director at time of discovery.

Based on record review and interview, the facility failed to ensure the automatic sprinkler and standpipe systems are inspected, tested and maintained in accordance with NFPA 25, and records are readily available as required by 9.7.5, 9.7.7, 9.7.8 and NFPA 25. This deficient practice could affect approximately 20 occupants in the event of a fire emergency.

Findings Include:
On April 13, 2021 at approximately 2:30 PM. review of the Clean Agent Inspection report dated October 12, 2020, revealed the facility failed to correct the impairment to the carbon dioxide extinguishing system. The report indicated the extinguishing system's pressure hoses were past due for hydrostatic testing.

The Director of Facilities and Director of Quality and Compliance confirmed these findings during the record review and at the time of the exit interview.

Based on record review and interview, the facility failed to ensure when the sprinkler system is out of service for more than 10 hours in a 24-hour period, the affected areas are evacuated or an approved Fire Watch is provided until the sprinkler system is returned to service as required by 19.3.5.1 and 9.7.5 of the LSC and 15.5.2 of NFPA 25. This deficient practice could affect all occupants in the event of a fire emergency or automatic fire sprinkler impairment.

Findings Include:
On April 14, 2021 at approximately 3:00 PM. review of the facility's Emergency Preparedness Plan dated May 7, 2017 revealed the facility failed to provide a fire watch policy in the event of an automatic sprinkler system impairment to include the correct phone number to contact the state when a fire watch is required.

The Director of Facilities and Director of Quality and Compliance confirmed these findings during the exit interview and at the time of record review.

Based on observation, record review and interview, the facility failed to ensure portable fire extinguishers are selected, installed, inspected and maintained in accordance with NFPA 10, as required by 19.3.5.12. This deficient practice could affect all occupants in the event of a fire emergency.

Findings Include:

On April 13, 2021, at approximately 1:30 PM, observation revealed the fire extinguisher located on 4th floor south next to the pantry room is missing from the damaged fire alarm cabinet. The extinguisher was observed at the nurse station on the table. This could potentially delay fire extinguishment and allow a fire to grow and spread without intervention. This finding was confirmed during interview with the maintenance director at the time of observation .

Based on observation and interview, the facility failed to ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits or hazardous areas are 1 3/4 inch solid-bonded core wood or capable of resisting the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed as required by 19.3.6.3, and 42 CFR 403, 418, 460, 482, 483 and 485. This deficient practice could affect 20 occupants in the event of a fire or smoke emergency.

Findings Include:

On April 14, 2021, at approximately 10:25 AM, observation revealed the 1st floor X-RAY storage room door number 158 does not close and come to a positive latch. The door has been damaged and will not fully close. This could potentially allow heat, smoke and fire to escape the room into the emergency egress corridor.


41647


On 4/13/2021, at approximately 9:56 AM, observation revealed door to the advanced rapid detoxification center on the 7th floor would not positively latch when closed. The inability of the door to positively latched could allow for the transfer of heat and smoke in the event of a fire.

On 4/13/2021, at approximately 11:37 AM, observation revealed door to nurse's workstation #530 on the 5th floor was being held open with a wood wedge.

On 4/14/2021, at approximately 10:08 AM, observation revealed door to the surgery break room on the 1st floor would not positively latch when closed. The inability of the door to positively latched could allow for the transfer of heat and smoke in the event of a fire.

The findings were confirmed by interview with the maintenance director at time of discovery.

Based on observation and interview, the facility failed to ensure doors in smoke barriers are 1-3/4 inch solid bonded wood-core doors or construction that resists fire for 20 minutes, are self-closing or automatic-closing and provide a minimum width of 32 inches as required by 19.3.7.6, 18.3.7.8 and 19.3.7.9. This deficient practice could affect more than a limited number of occupants in the event of fire emergency.

Findings Include:
On 4/13/2021, at approximately 11:30 AM, observation revealed rated door near room 638 on the 6th floor would not positively latch when closed. The inability of the door to positively latched could allow for the transfer of heat and smoke in the event of a fire.

On 4/13/2021, at approximately 11:34 AM, observation revealed rated door near room 537 on the 5th floor would not positively latch when closed. The inability of the door to positively latched could allow for the transfer of heat and smoke in the event of a fire.

On 4/13/2021, at approximately 2:20 PM, observation revealed between the old surgery/multi-specialty doors on the 3rd floor did not close to prevent the passing of smoke. The inability of the doors to seal could allow for the transfer of heat and smoke in the event of a fire.

On 4/14/2021, at approximately 10:40 AM, observation revealed 2-hour fire rated door near radiology waiting room/urgent care on the 1st floor would not positively latch when closed. The inability of the door to positively latched could allow for the transfer of heat and smoke in the event of a fire.

On 4/14/2021, at approximately 10:45 AM, observation revealed rated door to urgent care lobby on the 1st floor would not positively latch when closed. The inability of the door to positively latched could allow for the transfer of heat and smoke in the event of a fire.

On 4/14/2021, at approximately 11:00 AM, observation revealed storage room UC16 on the 1st floor would not positively latch when closed. The inability of the door to positively latched could allow for the transfer of heat and smoke in the event of a fire.

The findings were confirmed by interview with the maintenance director at time of discovery.

Based on observation and interview, the facility failed to ensure openings in smoke barrier doors were fire-rated glazing or wired glass panels in steel frames as required by 19.3.7.6, 19.3.7.6.2 and 8.5. This deficient practice could affect limited number of occupants in the event of fire emergency.

Findings Include:
On 4/13/2021 at approximately 11:17 AM, observation revealed the fire rated door window near room 625 was broken.

The findings were confirmed by interview with the maintenance director at time of discovery.

Based on record review and interview, the facility failed to ensure heating, ventilation and air conditioning is in compliance with 9.2, and installed in accordance with the manufacturer's specifications as required by 19.5.2.1 and 9.2. This deficient practice could affect all of the occupants in the event of a fire emergency.

Findings Include:
On April 13, 2021, at approximately 3:00 PM, records review revealed the facility failed to correct the impairments noted on the required damper inspection report conducted by Fire Alarm Services dated July 31, 2020. The inspection report indicated 84 fire dampers failed the required inspection and testing and no records were available to indicate the failed dampers had been corrected at the time of this survey.

The Director of Facilities and Director of Quality and Compliance confirmed these findings during interview and at the time record review.

Based on record review and interview, the facility failed to ensure fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions, are held at unexpected times under varying circumstances, conducted at least quarterly on each shift and responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership as required by 19.7.1.4 through 19.7.1.7. This deficient practice could affect all of the occupants in the event of a fire emergency.

Findings Include:
On April 13, 2021, at approximately 10:30 AM, record review revealed the facility failed to provide documentation that the alarm signals generated by the required fire drills were transmitted and received by the fire alarm monitoring company.

The Director of Facilities and Director of Quality and Compliance confirmed these findings during interview and at the time of record review.

Based on record review and interview, the facility failed to inspect and test annually in accordance with NFPA 101, 19.7.6, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives 5.2, 5.2.3. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. This deficient practice could affect all of the occupants in the event of a fire emergency.

Findings Include:
On April 13, 2021, at approximately 10:30 AM, record review revealed the facility failed to provide documentation of the annual inspection, testing and maintenance on the building's fire door assemblies in compliance with NFPA 80, 2010 edition. Documentation provided by the facility revealed the inspection of the fire door assemblies by the facility's staff did not meet NFPA 80, 2010 ed. requirements. The annual fire door inspection report by an outside vendor revealed 154 deficiencies in the facility's fire doors but did not indicate the location of the deficient doors.

The Director of Facilities and Director of Quality and Compliance confirmed these findings during interview and at the time of record review.

Based on observation and interview, the facility failed to ensure portable space heating devices shall be prohibited in all health care occupancies. Unless used in non-sleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit as required by 19.7.8. This deficient practice could affect 20 occupants in the event of a fire.

Findings Include:

1. On April 14, 2021, at approximately 10:50 AM, observation revealed a space heater in use in the employee health UC22 office. The space heater was on in an unoccupied office with a desk chair in close proximity to the heater. The back of the combustible office chair was hot to the touch. This could potentially cause a space heater related fire in the office area.

2. On April 14, 2021, at approximately 10:55 AM, observation revealed a space heater in use in the Security Office. The space heater was in close proximity to a box full of combustibles on the floor. The box was warm to the touch. This could potentially cause a space heater related fire in the security office area.

These findings were confirmed through interview with the maintenance director at the time of discovery.

Based on observation and interview, the facility failed to ensure power receptacles comply with the requirements of 6.3.2.2.6.2(F) and 6.3.2.4.2 of NFPA 99. This deficient practice could affect more than a limited number of occupants in the event of an electrical short circuit causing electrocution.

Findings Include:

A. On 4/13/2021, between 10:02 AM - 10:36 AM, observation revealed the following locations on the 7th floor: clean supply room 771, pantry room 772, medication room 774, and patient rooms 756 - 768 and 701 - 725 had electrical receptacles within 6 feet of the water source that are not ground fault protected per NFPA 70, Chapter 210.8(B)(1)(2)(5). This could potentially allow an individual to be electrocuted without the protection of the required outlet.

B. On 4/13/2021, at 11:40 AM, observation revealed pantry room 529 on the 5th floor had electrical receptacles within 6 feet of the water source that are not ground fault protected per NFPA 70, Chapter 210.8(B)(1)(2)(5). This could potentially allow an individual to be electrocuted without the protection of the required outlet.

C. On 4/13/2021, at 1:44 PM, observation revealed clean utility room 478 on the 4th floor had electrical receptacles within 6 feet of the water source that are not ground fault protected per NFPA 70, Chapter 210.8(B)(1)(2)(5). This could potentially allow an individual to be electrocuted without the protection of the required outlet.

D. On 4/13/2021, at 2:00 PM, observation revealed pantry room 429 on the 4th floor had electrical receptacles within 6 feet of the water source that are not ground fault protected per NFPA 70, Chapter 210.8(B)(1)(2)(5). This could potentially allow an individual to be electrocuted without the protection of the required outlet.

E. On 4/13/2021, at 2:16 PM, observation revealed the 3rd floor lobby of family practice offices had electrical receptacles within 6 feet of the water source that are not ground fault protected per NFPA 70, Chapter 210.8(B)(1)(2)(5). This could potentially allow an individual to be electrocuted without the protection of the required outlet.

F. On 4/13/2021, at 3:05 PM, observation revealed the 2nd floor laboratory had electrical receptacles within 6 feet of the water source that are not ground fault protected per NFPA 70, Chapter 210.8(B)(1)(2)(5). This could potentially allow an individual to be electrocuted without the protection of the required outlet.

G. On 4/14/2021, between 10:11 AM, observation revealed anesthesia work room 197 on the 1st floor had electrical receptacles within 6 feet of the water source that are not ground fault protected per NFPA 70, Chapter 210.8(B)(1)(2)(5). This could potentially allow an individual to be electrocuted without the protection of the required outlet.

The findings were confirmed by interview with the maintenance director at time of discovery.

Based on observation, record review and interview, the facility failed to ensure generators or other alternative power sources and associated equipment is capable of supplying service within 10 seconds, is maintained, inspected, tested and exercised in accordance with NFPA 110, and records are readily available as required by 6.4.4, 6.5.4 and 6.6.4 of NFPA 99, NFPA 110, NFPA 111 and 700.10 of NFPA 70. This deficient practice could affect all of the occupants in the event of a fire emergency or facility wide power outage.

Findings Include:
A) On April 14, 2021, at approximately 09:00 AM, record review revealed the facility failed to document a battery test on the required monthly inspection of the facility's generator. The monthly test of the battery must include the specific gravity of the battery fluids or cold crank amperage if the battery is of a maintenance free design to ensure the cells are in operational condition. Record review revealed the facility only recorded the required battery test one month (January 2021) in the last year.

B) On April 14, 2021, at approximately 09:00 AM, record review revealed the facility failed to maintain the fuel for the facility's #1 emergency generator to NFPA 110 standards. Record review of the fuel sample for tank #1 that supplied generator #1 failed the annual fuel test due to substandard thermal stability.

C) On April 14, 2021, at approximately 2:00 PM, observation revealed the facility failed to provide a battery back-up emergency light to illuminate the generator's transfer switch room in the event of a power loss and failure of the transfer switch to operate per Chapter 7.3 in NFPA 110 2010 edition.

D) On April 14, 2021, at approximately 2:00 PM, observation revealed the facility failed to maintain the remote annunciator panel located on the 1st floor of the power plant building. The panel was observed with all the indicator lights flashing and interview with the facility maintenance director revealed the panel was not in communication with the #1 generator.

The Director of Facilities and Director of Quality and Compliance confirmed these findings during interview and at the time of observation.