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Based on Document Review and Staff Interview with the Facilities Director during the course of the survey conducted on 10/25/2017, it was determined the facility failed to meet Emergency Lighting Testing and Maintenance requirements in accordance with NFPA 101, 19.2.9.1.

This was evidenced by the following:

1. No records were available for the required 90-minute emergency lighting test, and the Facilities Director confirm the test had not been performed within the last year.

The Facilities Director was present when the deficiency was identified.

Failure to maintain building emergency lighting Testing and Maintenance requirements increases the risk of death or injury due to fire.

The Life Safety deficiency has the potential to affect all occupants, who might include staff, residents and visitors within two of two smoke compartments.

This/these deficiencies were discussed during the survey with the Facilities Director, and again during the exit interview with the Hospital CEO/CMO and staff.

Based on observation, document review, and staff interview during the course of the survey conducted on 10/25/2017, it was determined the facility failed to meet the requirements for commercial kitchens in accordance with NFPA 96.

This was evidenced by the following:

1. The cooking appliances equipped with casters were observed to not have wheel stops installed to ensure proper alignment with the suppression nozzles as required by NFPA 96.

2. Document review revealed, and staff interview with the Facilities Director confirmed the hood duct system had not been cleaned on over 1-year where required to be cleaned every six months.

The Facilities Director was present when the deficiency was identified.

Failure to maintain commercial kitchen requirements increases the risk of death or injury due to fire.

The protection deficiency has the potential to affect all occupants, who might include staff, residents and visitors within one of two smoke compartments.

This/these deficiencies were discussed during the survey with the Facilities Director, and again during the exit interview with the Hospital CEO/CMO and staff.

Based on Document Review and Staff Interview with the Facilities Director during the course of the survey conducted on 10/25/2017, it was determined the facility failed to meet Fire Alarm Testing and Maintenance requirements in accordance with NFPA 72.

This was evidenced by the following:

1. No documentation for the Annual Fire Alarm Inspection was available at the time of the survey, and the Facilities Director confirmed through staff interview, that the annual inspection had not been performed within the last year. The Faculties Director did state that the inspection was scheduled to be performed within two weeks.

2. No documentation for the Bi-Annual Fire detector sen activity test was available at the time of the survey, and the Facilities Director confirmed through staff interview, that the bi-annual test had not been performed within the last two years. The Facilities Director did state that the inspection was scheduled to be performed within two weeks.

3. The FACP batteries located in the main FACP were observed during the walk-through portion of the survey to be missing the required dates when they entered serviced on them.

The Facilities Director was present when the deficiency was identified.

Failure to maintain building Fire Sprinkler Testing and Maintenance requirements increases the risk of death or injury due to fire.

The construction rating deficiency has the potential to affect all occupants, who might include staff, residents and visitors within two of two smoke compartments.

This/these deficiencies were discussed during the survey with the Facilities Director, and again during the exit interview with the Hospital CEO/CMO and staff.

Based on observation during the course of the survey conducted on 10/25/2017, it was determined the facility failed to meet the Fire Sprinkler installation requirements in accordance with NFPA 13.

This was evidenced by the following:

The combustible canopy located outside the ER Waiting Entrance, greater than four feet in width from the building, was observed to have no sprinkler protection in a building noted as "Fully Sprinklered."

The Facilities Director was present when the deficiency was identified.

Failure to maintain building sprinkler installation requirements increases the risk of death or injury due to fire.

The protection deficiency has the potential to affect all occupants, who might include staff, residents and visitors within one of two smoke compartments.

This/these deficiencies were discussed during the survey with the Facilities Director, and again during the exit interview with the Hospital CEO/CMO and staff.

Based on Document Review and Staff Interview with the Facilities Director during the course of the survey conducted on 10/25/2017, it was determined the facility failed to meet Sprinkler Testing and Maintenance requirements in accordance with NFPA 25.

This was evidenced by the following:

1. The Fire Sprinkler wet pipe obstruction inspection, due every five years, had not been performed within the last five years. The Facilities Director stated the inspection is currently scheduled to be completed.

2. The fire sprinkler escutcheon in the Pharmacy Positive Pressure Room was observed to be held in place by vinyl tape.

3. One of four sprinkler heads located in the Operating Room was observed to be missing its cover.

The Facilities Director was present when the deficiency was identified.

Failure to maintain building Fire Sprinkler Testing and Maintenance requirements increases the risk of death or injury due to fire.

The fire sprinkler deficiencies has the potential to affect all occupants, who might include staff, residents and visitors within two of two smoke compartments.

This/these deficiencies were discussed during the survey with the Facilities Director, and again during the exit interview with the Hospital CEO/CMO and staff.

Based on observation during the course of the survey conducted on 10/25/2017, it was determined the facility failed to meet the requirements for portable fire extinguishers in accordance with NFPA 10.

This was evidenced by the following:

1. The portable fire extinguisher located in the Staff Break Room was observed to have not been checked monthly, as indicated by the service tag.

2. The type ABC portable fire extinguisher located in the kitchen was observed to be obstructed by a portable table located in front of the extinguisher.

The Facilities Director was present when the deficiency was identified.

Failure to maintain portable fire extinguisher requirements increases the risk of death or injury due to fire.

The protection deficiency has the potential to affect all occupants, who might include staff, residents and visitors within one of two smoke compartments.

This/these deficiencies were discussed during the survey with the Facilities Director, and again during the exit interview with the Hospital CEO/CMO and staff.

Based on observation during the course of the survey conducted on 10/25/2017, it was determined the facility failed to meet the building separation requirements in accordance with NFPA 101.

This was evidenced by the following:

Open penetrations in the 2-hr occupancy separation fire-rated wall assembly at room B129 were observed.

The Facilities Director was present when the deficiency was identified.

Failure to maintain building separation requirements increases the risk of death or injury due to fire.

The protection deficiency has the potential to affect all occupants, who might include staff, residents and visitors within two of two smoke compartments.

This/these deficiencies were discussed during the survey with the Facilities Director, and again during the exit interview with the Hospital CEO/CMO and staff.

Based on Document Review and Staff Interview with the Facilities Director during the course of the survey conducted on 10/25/2017, it was determined the facility failed to meet Sprinkler Testing and Maintenance requirements in accordance with NFPA 101.

This was evidenced by the following:

1. No documentation for the 6-year Smoke/Fire Damper operational Test/Inspection was available at the time of the survey, and the Facilities Director confirmed through staff interview, that the inspection had not been performed within the last six years.

The Facilities Director was present when the deficiency was identified.

Failure to maintain building Smoke/Fire Damper Testing and Maintenance requirements increases the risk of death or injury due to fire.

The Building Services deficiency has the potential to affect all occupants, who might include staff, residents and visitors within two of two smoke compartments.

This/these deficiencies were discussed during the survey with the Facilities Director, and again during the exit interview with the Hospital CEO/CMO and staff.

Based on Document Review and Staff Interview with the Facilities Director during the course of the survey conducted on 10/25/2017, it was determined the facility failed to Fire Drill requirements in accordance with NFPA NFPA 101, Chapter 19.

This was evidenced by the following:

1. No documentation for the Quarterly Fire Drills was available at the time of the survey for any shift between September 2016 and March 2017, and the Facilities Director confirmed through staff interview, that not all fire drills were conducted within the required timeframe as stated in NFPA 101, Chapter 19.

2. No documentation for the Quarterly Fire Drills was available at the time of the survey for Third Shift (2200 - 0600) between September 2016 and August 2017, and the Facilities Director confirmed through staff interview, that not all fire drills were conducted within the required timeframe as stated in NFPA 101, Chapter 19.

The Facilities Director was present when the deficiency was identified.

Failure to meet fire drill requirements increases the risk of death or injury due to fire.

The building services deficiency has the potential to affect all occupants, who might include staff, residents and visitors within two of two smoke compartments.

This/these deficiencies were discussed during the survey with the Facilities Director, and again during the exit interview with the Hospital CEO/CMO and staff.

Based on observation during the course of the survey conducted on 10/25/2017, it was determined the facility failed to meet the generator installation requirements in accordance with NFPA 110 for the Type I EPSS.

This was evidenced by the following:

1. The Generator was observed to have no Emergency Stop Device installed outside of the generator housing as required by NFPA 110, para. 5.6.5.6.

The Facilities Director was present when the deficiency was identified.

Failure to maintain building generator installation requirements increases the risk of death or injury due to fire.

The Health Care Facilities Code deficiency has the potential to affect all occupants, who might include staff, residents and visitors within two of two smoke compartments.

This/these deficiencies were discussed during the survey with the Facilities Director, and again during the exit interview with the Hospital CEO/CMO and staff.