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Based on record review and staff interview, the facility failed to test the battery system of the emergency generator. This condition increased the likelihood of the generator failing to start during loss of power.

Findings are:

Record review of monthly generator load test reports on 6/25/25 at 12:51 pm revealed there was no documentation of monthly specific gravity testing or conductance testing for the lead-acid batteries.

In an interview on 6/25/25 at 12:51 pm, Maintenance A confirmed the generator battery was not tested, but only the voltage readings were taken from the generator panel.

NFPA 110, 2010, 8.3.7.1 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.

Based on observation and staff interview, the facility failed to provide a means to ensure the range was correctly positioned under the suppression system nozzles, and that the appliance was anchored to protect the natural gas connection. This condition would increase the probability of a gas leak or failure to suppress a cooking fire.

Finding are:
Observation on 6/25/25, at 12:00 pm revealed:
1. The range was not provided with floor markings or wheel chocks to ensure the range was returned to an aligned position with the range hood suppression system nozzles when the appliance is moved.
2. The range was not anchored to prevent the natural gas hose from disconnecting when the appliance is moved.

In an interview on 6/25/25, at 12:00 pm, Maintenance A confirmed the findings.

NFPA 17A, 2009, 5.6.4 Movable cooking equipment shall be provided with a means to ensure that it is correctly positioned in relation to the appliance discharge nozzle during cooking operations.
NFPA 54, 2012, 9.6.1.1 Commercial Cooking Appliances. Commercial cooking appliances that are moved for cleaning and sanitation purposes shall be connected in accordance with the connector manufacturer's installation instructions using a listed appliance connector complying with ANSI Z21.69/CSA 6.16, Connectors for Movable Gas Appliances. The commercial cooking appliance connector installation shall be configured in accordance with the manufacturer's installation instructions. 9.6.1.2 Restraint. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer's installation instructions.

Based on observation and staff interview, the facility failed to ensure the fire alarm circuit was properly identified and secured. This condition increased the potential that power to the fire alarm would be shut off when not intended.

Findings are:
Observation on 6/25/25 at 11:35 am revealed circuit breakers that fed fire alarm panels were not marked in red or locked in life safety panel XLS1.

In an interview on 6/25/25 at 11:35 am, Maintenance A confirmed the findings.

NFPA 72, 2010, 10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking.
10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel.

Based on observation, record review and staff interview, the facility failed to have fire sprinkler gauges replaced or tested at the required 5-year interval. This condition increased the potential for false pressure readings.

Findings are:
Observation on 6/25/25 at 11:44 am revealed gauges on the main fire sprinkler riser were dated 2019.

Record review on 6/25/25, at 11:44 am of the 1/9/25 fire sprinkler inspection report did not indicate testing of the gauges.

In an interview on 6/25/25 at 11:44 am, Maintenance A confirmed the gauges were dated 2019, and that no other documentation was available.

NFPA 25, 2011, 5.3.2* Gauges. 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge.

Based on record review and staff interview, the facility failed to limit circuits essential to life safety on a life safety branch of the essential electrical system (EES). This condition increased the potential of EES failure.

Findings are:
Record review on 6/25/25 at 11:36 am of the life safety panel XLS1 panel schedule revealed the following circuits were not life safety items or could not be adequately identified: 7: main server, 13: illegible, 23/25: illegible, 27: office/illegible, 29: mechanical room, 31/33 basement, 4: telephone board recepts, 6: telephone board recepts, 8: telephone board recepts, 20: UPS-COS-CLOS, 30: UPS Business Office.

In an interview on 6/25/25 at 11:36 am, Maintenance A acknowledged not all items in the panel were life safety, or was unsure of the descriptions.

NFPA 99, 2012, 6.4.2.2.3 Life Safety Branch. 6.4.2.2.3.1 The life safety branch shall be limited to circuits essential to life safety. 6.4.2.2.3.2 The life safety branch shall supply power for lighting, receptacles, and equipment as follows: (1) Illumination of means of egress in accordance with NFPA 101, Life Safety Code (2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code (3)*Hospital communications systems, where used for issuing instruction during emergency conditions (4) Generator set location as follows: (a) Task illumination (b) Battery charger for emergency battery-powered lighting unit(s) (c) Select receptacles at the generator set location and essential electrical system transfer switch locations (5) Elevator cab lighting, control, communications, and signal systems (6) Electrically powered doors used for building egress (7) Fire alarms and auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm and Signaling Code 6.4.2.2.3.3 Alarm and alerting systems (other than fire alarm systems) shall be connected to the life safety branch or critical branch. 6.4.2.2.3.4 Loads dedicated to a specific generator, including the fuel transfer pump(s), ventilation fans, electrically operated louvers, controls, cooling system, and other generator accessories essential for generator operation, shall be connected to the life safety branch or the output terminals of the generator with overcurrent protective devices. 6.4.2.2.3.5 No functions other than those in 6.4.2.2.3.2, 6.4.2.2.3.3, and 6.4.2.2.3.4 shall be connected to the life safety branch, except as specifically permitted in 6.4.2.2.3.

Based on record review and staff interview, the facility failed to test the battery system of the emergency generator. This condition increased the likelihood of the generator failing to start during loss of power.

Findings are:

Record review of monthly generator load test reports on 6/25/25 at 12:51 pm revealed there was no documentation of monthly specific gravity testing or conductance testing for the lead-acid batteries.

In an interview on 6/25/25 at 12:51 pm, Maintenance A confirmed the generator battery was not tested, but only the voltage readings were taken from the generator panel.

NFPA 110, 2010, 8.3.7.1 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.