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Based on observations and staff interview, the facility failed to ensure that the smoke barriers were maintained in accordance with NFPA 101 19.3.7.3 and 8.3.



Findings include:

Observation on 09-15-15 revealed that at approximately 11:25 hrs the smoke barrier wall next to the nurses station had an open penetration approximately 12"X 12"in size. This was located above the drop ceiling. This was verified by the Director of Maintenance at the time of discovery and the Administrator during the exit interview on 09-15-15 at approximately 13:00 hrs.

Based on observation and staff interview, the facility failed to ensure that the hazardous areas were protected in accordance with NFPA 101 8.4.1, 19.3.5.4 and 19.3.2.1.

Findings include:

Observation on 09-15-15 revealed that at approximately 10:50 hrs the door to the janitors closet which contain combustible storage was not self closing when tested. This was verified by the Director of Maintenance at the time of discovery and the Administrator during the exit interview on 09-15-15 at approximately 13:00 hrs.

Based on record review and staff interview, the facility failed to ensure that the fire drills were conducted in accordance with NFPA 101 19.7.1.2.

Findings include:

Record review on 09-15-15 revealed that at approximately 09:00 hrs there was no documentation to show that the following fire drills were completed:
1. 3rd quarter for 2nd shift weekday 2014
2. 1st quarter for 2nd shift weekday 2015
3. 2nd quarter for 1st and 2nd shifts weekend 2015
4. 3rd quarter for 2nd shift weekday 2015
This was verified by the Director of Maintenance at the time of discovery and the Administrator during the exit interview on 09-15-15 at approximately 13:00 hrs.

Based on observations and staff interview, the facility failed to ensure that the automatic sprinkler system was installed in accordance with NFPA 101 19.3.5 and NFPA 13.



Findings include:

Observation on 09-15-15 revealed that at approximately 11:05 hrs there was no sprinkler protection or alternative protection measures for the IT room. This was verified by the Director of Maintenance at the time of discovery and the Administrator during the exit interview on 09-15-15 at approximately 13:00 hrs.

Based on record review and staff interview, the facility failed to ensure that the generator was maintained in accordance with NFPA 99 and NFPA 110.



Findings include:

Record review on 09-15-15 revealed that at approximately 09:00 hrs there was no documentation to show that the generator was run unload for the months of April and July for 2015. Also the only weekly inspection logs were for the month of January 2015. This was verified by the Director of Maintenance at the time of discovery and the Administrator during the exit interview on 09-15-15 at approximately 13:00 hrs.

Based on observations and staff interview, the facility failed to ensure that the electrical wiring and equipment is maintained in accordance with NFPA 70.



Findings include:

Observation on 09-15-15 revealed that:
1. At approximately 10:45 hrs the IT department had a power strip plugged into a power strip.
2. At approximately 11:30 hrs the nursing computer serial number FMH-NUR-COW5 had a frayed power cord at the plug. This was verified by the Director of Maintenance at the time of discovery and the Administrator during the exit interview on 09-15-15 at approximately 13:00 hrs.