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Based on observation and staff interview, the facility failed to provide doors in accordance with the 2012 NFPA 101 (Life Safety Code). Failure to provide doors as required by the NFPA 101 may result in injury or death due to a fire. The deficiency affected 1 of 5 exterior exit doors. The findings were:

Observation on 4/10/2018 at 9:25 AM located adjacent to the stage revealed an exit door to the exterior that when tested to open required more than 50 pound force to open.

Interview with the facility staff B at the time of observation indicated that the facility was aware of the requirement. Interview with the facility administrator at the time of survey exit acknowledged the deficiency.

Ref:
2012 NFPA 101 (LSC) - Section - 19.2.2, 7.2, 7.2.1.4.5.1

Based on observation and staff interview, the facility failed to maintain emergency battery powered light systems as required per 2012 NFPA 101 (Life Safety Code). Failure to maintain emergency battery-powered lights as required may result to injury of death due to a fire. The deficiency affected one of one emergency battery-powered lights. The findings were:

Observation on 4/10/2018 at 10:28 AM revealed an emergency battery-powered light located in the transfer switch room that when tested would not illuminate.

Interview with the facility staff B at the time of observation indicated that they were unaware they were not working.
Interview with the facility administrator at the time of survey acknowledged the deficiency.

Ref:
2012 NFPA 101 (LSC) - Sections - 19.2.9, 7.9, 7.9.2.3

Based on observation and staff interview, the facility failed to provide protection from hazards in accordance with the 2012 NFPA 101 (Life Safety Code). Failure to provide protection from hazards as required per NFPA 101 may result in injury or death due to a fire. The deficiency affected 1 of 4 corridors. The findings were:

Observation on 4/10/2018 at 10:58 AM located in the 322 corridor of the Karn building revealed storage of combustible goods. Further observation revealed clean linen and medical supplies located in the corridor.

Interview with the facility staff B at the time of observation indicated that they were unaware of the requirement. Interview with the facility administrator at the time survey exit acknowledged the deficiency.

Ref:
2012 NFPA 101 (LSC) - Section - 19.3.2

Based on observation and staff interview, the facility failed to provide smoke detection in accordance with the 2010 NFPA 72 (National Fire Alarm and Signaling Code). Failure to provide smoke detection as required may lead to injury or death due to a fire. The deficiency affected less than 10 percent of the smoke detectors in the facility. The findings were:

Observation on 4/10/2018 at 1:32 PM located in the garage revealed a smoke detector that had the original plastic placed over the top of the smoke detector.

Interview with the facility staff B at the time of observation indicated they were unaware the cover was still on the smoke detector. Interview with the facility administrator at the time of survey exit acknowledge the deficiency.

REF:
2012 NFPA 101 (LSC) - Sections - 19.3.4.1, 9.6.2.10.1
2010 NFPA 72 Sections (National Fire Alarm & Signaling Code) - Section - 14.5.1

Based on observation, document review, and staff interview, the facility failed to provide annual sprinkler testing as required per the 2010 NFPA 13 (Sprinkler installation). Failure to provide annual testing as required per NFPA 13 may result in death or injury due to fire. The deficiency affected the whole building and all smoke compartments within it. The findings were:

Observation on 4/10/2018 at 9:36 AM located at the sprinkler riser revealed that the sprinkler riser had not received an annual inspection since 2016.

During document review the fire sprinkler results from 2017 revealed that the sprinkler contractor indicated the system as not tested.

Interview with the facility staff B at the time of observation indicated that the facility was unaware that the building had not had an annual inspection for 2017. Interview with the facility administrator at the time of survey acknowledged the deficiency.

Ref:
2012 NFPA 101 (LSC) - Sections - 19.3.5.3, 9.7, 9.7.1.1
2011 NFPA 13 (Inspection, Testing, And Maintenance of Water-Based Fire Protection Systems) - Section - Table 5.1.1.2

Based on observation and staff interview, the facility failed to provide electrical receptacle in accordance with the 2010 NFPA 70 (National Electric Code). Failure to provide electrical receptacle as required by NFPA 70 may result in injury or death due to electrical shock. The deficiency affected less than 10 percent of all receptacles in the facility. The findings were:

Observation on 4/10/2018 at 1:19 PM located at the laboratory sink revealed a sink within 6 feet of an electrical receptacle. Further observation revealed that the electrical receptacle was not equipped with ground fault circuit interruption.

Interview with the facility staff B at the time of observation indicated they were aware of the requirement. Interview with the facility administrator at the time of survey exit acknowledged the deficiency.

Ref:
2012 NFPA 101 (LSC) - Section - 19.5, 19.5.1.1, 19.5.1.2, 9.1, 9.1.2
2011 NFPA 70 (National Electric Code) - Section - 210.8(B)(5)

Based on observation and staff interview, the facility failed to provide a generator annunciator panel in accordance with 2012 NFPA 99. Failure to provide a generator annunciator panel in accordance with NFPA 99 may lead to death or injury in an emergency situation. The deficiency affected one of one generators that affects the whole building. The findings were:

Observation on 4/10/2018 at 2:05 PM located at the central nurses station revealed a generator annunciator panel that when tested would not send an audible alarm.

Interview with the facility staff B at the time of observation indicated that they were unaware of the requirement. Interview with the facility administrator at the time of the survey exit acknowledged the deficiency.

Further interview with facility administrator and facility staff B at the time of exit indicated that the generator annunciator panel was also not located at a point where it is observed for 24 hours.

Ref:
2012 NFPA 99 (Health Care Facilities Code) - Section - 6.4.1.1.17.1, 6.4.1.1.17.4