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Based on observation and interview the facility failed to ensure illumination of means of egress to include exit discharge is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention in accordance to NFPA 101, 2012 Edition Chapter 19.2.8.

Findings:

On 06/06/17 at 3:07 pm, each of the exit discharges of the facility were observed to have lighting fixtures on normal power.

On 06/06/17 at 3:07 pm, the maintenance manager stated he did not know the existing light fixtures located at each exit discharge were wired to or were powered by the emergency generator.

Based on record review and interview the facility failed to ensure fire rated door assemblies were tested, inspected and maintained annually as required in NFPA 80, Section 5.2.3, 5.3, and 5.4.

Findings:

On 06/06/17 at 10:43 am the maintenance manager was asked for the annual documentation for the facility fire rated door assemblies testing, inspection and maintenance. He said they do not have the fire rated door assembly documentation and were not aware of the requirement.

Based on observation and interview the facility failed to ensure all electrical wiring and equipment were in accordance with the National Electrical Code standards of compliance.

Findings:

On 06/06/17 at 3:22 pm an extension cord was observed to be plugged into a floor fan in the physical therapy department.

On 06/06/17 at 3:23 pm a hydroculator was observed to be plugged into a non-GFCI eletrical receptacle.

On 06/06/17 at 3:23 pm the maintenance manager acknowledged the extension cord and the hydroculator plugged into a non-GFCI receptacle and said he would remove them as soon as possible.

National Electrical Code, NFPA 70, NFPA 99- 2012 Edition, NFPA 101- 2012 Edition.

Based on record review, observation and interview the facility failed to ensure heating ventilation and air was installed per manufactures guidelines as required.

Findings:

On 06/06/17 at 11:46 am record review of the facility's medical gas annual certification dated May 24-25, 2016 showed a deficiency of a medical air intake vent had an exhaust vent within 25 feet from it.

On 06/06/17 at 11:46 am during an interview with the maintenance manager was asked if the exhaust vent was corrected. He said no that they have not.

Based on interview and record review the facility failed to ensure completing building systems risk assessment for their medical gas systems as required in NFPA 99, 2012 Edition, Chapter 4.

Findings:

On 06/06/17 at 11:37 am the maintenance manager was asked for their building systems risk assessments to include medical gas systems. During record review the maintenance manager failed to provide the medical gas risk assessment.

Based on record review and interview the faclity failed to ensure the facility medical gas system was maintaned in good working order as required per NFPA 99, 2012 Edition.

Findings:

On 06/06/17 at 10:43 am on review of the facility's annual medical gas inspections dated 05/25/16 and 05/03/17 from Airgas/Apex Medical Gas Systems respectively indicated the medical alarms should be replaced, the facility medical air system should be replaced in order to be compliant. The facility medical vacuum and oxygen manifold was not working properly and needed repairs.

On 06/06/17 at 11:04 am the maintenance manager was asked if the recommended repairs have been completed. He stated no. He was asked why the outlined repairs have not been completed which are written in the Airgas inspection report dated 05/25/17 and the Apex Medical Gas Systems inspection report dated 05/25/16. He said that he has only been at this faclity for a short time and did not get to it.

Based on record review and interview the facility failed to ensure completing building systems risk assessments for the facility's essential electric system were completed as required in NFPA 99, 2012 Edition, Chapter 4.

Findings:

On 06/06/17 at 10:32 am the maintenance manager was asked for the building systems risk assessments that includes their essential electric system categories. During record review the maintenance manager failed to provide the essential electric system risk assessment.

Based on record review and interview the facility failed to ensure all electrical wiring and equipment in use were inspected, maintained and tested as required.

Findings:

On 06/06/17 at 2:20 pm a Helmer medication only refrigerator in the facility pharmacy was observed to not have a current inspection sticker.

On 06/06/17 at 2:20 pm the maintenance manager was asked why it had not been inspected and he stated he did not know it should have been done.