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Based on record review and interview with the Director of Facilities, it was determined that the facility did not conduct the annual emergency lighting test for 2016.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " Section 7.9.3.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional Testing shall be conducted monthly with a minimum of 3 weeks and a maximum of 5 weeks between tests. for not less than 30 seconds except as otherwise permitted by 7.9.3.1.1.(2) The Test interval shall be permitted to be extended beyond 30 days with the approval of authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1/1/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings include:

On October 24, 2017, the surveyor accompanied by the Director of Facilities reviewed the emergency lighting testing documentation. All monthly test were conducted but no annual test for 2016 was documented on the forms.

During the exit conference on October 25, 2017, the above findings were again acknowledged by the Chief Executive Officer, Chief Clinical Officer, Chief Financial Officer, and Director of Facilities.

Failing to maintain and test emergency lighting units in time of an emergency could cause harm to the patients in an emergency power outage.

Based on observation, it was determined two (2) doors in the Medical/Surgical wing of the hospital did not have a door closure on the doors, to self or automatic close and latch in a hazardous area.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.1, Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Findings Include:

On October 24, 2017, the surveyor accompanied by the Director of Facilities, observed the janitor closet and housekeeping closet in the Medical/Surgical wing of the hospital, did not have a door closure on the door to self close or automatic close and latch in a hazardous area. The door was a sliding push type door and had to be pulled by hand to close.

During the exit conference on October 25, 2017, the above findings were again acknowledged by the Chief Executive Officer, Chief Clinical Officer, Chief Financial Officer, and Director of Facilities.

Failing to install self-closing hardware on a smoke/fire resistance door to a hazardous room could cause harm to patients in time of a fire.

Based on record review and interview with the Director of Facilities, it was determined the facility failed to provide reports/documentation to demonstrate the sprinkler system was tested semi-annually in 2017.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition, "Water Based Extinguishment Systems," requires monthly, quarterly and annual testing of automatic sprinkler systems.

Findings include:

On October 24, 2017, the surveyor, accompanied by the Director of Facilities reviewed the an Annual sprinkler inspection and test report dated 2/9/2017 by [name of fire inspection company]. The facility did not have any other sprinkler reports within six (6) months to show it was tested.

During the exit conference on October 25, 2017, the above findings were again acknowledged by the Chief Executive Officer, Chief Clinical Officer, Chief Financial Officer, and Director of Facilities.

Failing to inspect test and maintain the sprinkler system quarterly could cause the system to be inoperable due to lack of maintenance during a fire, and could cause harm to,the residents.

Based on observation, it was determined the facility failed to fill penetrations in two of the smoke barriers in the facility.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

On October 24, 2017, the surveyor accompanied by the Director of Facilities observed unsealed penetrations in the smoke barriers in the following locations:

1. Service hall corridor, four (4) penetrations in the smoke barrier.
2. Medical/Surgical hall, two (2) penetrations in the smoke barrier.

During the exit conference on October 25, 2017, the above findings were again acknowledged by the Chief Executive Officer, Chief Clinical Officer, Chief Financial Officer, and Director of Facilities.

Failing to seal the penetrations, holes and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which could cause harm to the patients in the event of a fire.

Based on record review and interview, with the Director of Facilities it was determined that there were no fire drill documentation for second quarter day shift 2016, nor was there any fire drill documentation for first quarter day and night shift 2017.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.2.2 written health care occupancy fire safety plan shall provide for the following:

1. Use of alarms
2. Transmission to the fire department
3. Emergency phone call to the fire department
4. Response to alarms
5. Isolation of fire
6. Evacuation of immediate area
7. Evacuation of smoke compartment
8. Preparation of floors and building for evacuation
9. Extinguishment of fire.

Findings include:

On October 24, 2017, the surveyor in conjunction with the Director of Facilities reviewed the fire drills. There was no evidence that any fire drills had occurred for second quarter day shift 2016, nor was there any fire drill documentation for first quarter day and night shift 2017.

During the exit conference on October 25, 2017, the above findings were again acknowledged by the Chief Executive Officer, Chief Clinical Officer, Chief Financial Officer, and Director of Facilities.

Failing to conducted the fire drills in accordance with the life safety code to familiarize staff with conditions under an actual fire can result in harm to patients and staff during an actual fire or emergency situation.

Based on record review and interview with the Director of Facilities, it was determined the facility failed to document the required testing of the emergency generator for the monthly under load test transfer times for the emergency generator.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES" 2012, Chapter 6, Section 6.4.4.1.1.4 (A) Test Criteria. Generator sets shall be tested 12 times a year with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standards for Emergency and Standby Power Systems, Chapter 8. Operational Inspection and Testing. Section 8.4.1 EPPS, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly."

Findings Include:

On October 24, 2017, the surveyor, accompanied by the Director of Facilities reviewed the generator test records. No documentation of monthly under load testing transfer times was available to review from January of 2016 to September of 2017.

During the exit conference on October 25, 2017, the above findings were again acknowledged by the Chief Executive Officer, Chief Clinical Officer, Chief Financial Officer, and Director of Facilities.

Failure to visually inspect and document the emergency generator could result in harm to patients during emergency system failures.

Based on observation, it was determined the facility failed to ensure staff did not use multiple outlet adapters, power strips and extension cords and staff use the wall outlet receptacles for appliances.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On October 24, 2017 the surveyor, accompanied by the Director of Facilities, observed the following strips in the facility,and not directly plugged in to the receptacle wall outlets.

1. Daisy chained auxiliary power unit with multiple outlets, plugged into a power strip in the Chief Financial Officer office.

2. Ice room, in the Medical/Surgical wing, two (2) refrigerators plugged into a power strip and not directly into a receptacle wall outlet.

During the exit conference on October 25, 2017, the above findings were again acknowledged by the Chief Executive Officer, Chief Clinical Officer, Chief Financial Officer, and Director of Facilities.

The use of multiple outlet adapters could create an overload of the electrical system, and could cause a fire or an electrical hazard. A fire could cause harm to the patients.