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Based on a validation survey, observations made during the survey for life safety from fire , it was determined that the facility failed to ensure that the automatic extinguishing system above the stove is appropriately designed and maintained as required by the 2012 edition of the Life Safety Code of the NFPA Section 9.2.3, 19.3.2.6 and NFPA 96.

Findings include:

1. The automatic extinguishing system above the stove was observed on 5/9/17 at 9:15 am with (employee #13) and evidence of the following was not provided:

a. Verification that activation of the extinguishing system activates the facility's fire alarm.

2. During the observational tour of the kitchen on 5/9/17 at 9:15 am following was determined:

a. One of the hood vents were found without ANSUL system.

b. Kitchen's hood exhaust system maintenance was requested, however no evidence was found of the updated required hood, duct and exhaust fans inspection by a properly trained, qualified and certified company or person in accordance with the manufacturer's exhaust system inspection schedule.

Based on a validation survey, observations made during the survey for life safety from fire , it was determined that the facility failed to ensure that at a portable fire extinguishers is available in the storage area of the Kitchen as required by the 2012 edition of the Life Safety Code of the NFPA Section 9.7.4.1 and NFPA 10.

Findings include:

The storage of the kitchen was visited on 5/9/17 at 9:15 am and it was found that this area contains a large amount of boxes. There is a smoke detector but it is not connected to the alarm panel also it is not included on the monthly tests. The placement of the fire extinguisher should be place near the entrance of every room in order to facilitate its use.

Based on a validation survey, tests to doors and observations made during the survey for life safety from fire, it was determined that patient's doors protecting corridors at rooms #118 and #122 do not close completely (do not latch) as required by the 2012 edition of the Life Safety Code of the NFPA Section 19.3.6.3.

Findings include:

During the tour for life safety from fire on 7/8/10 at 2:40 pm, patient's sleeping room doors were tested it was found that patient's sleeping rooms #118 and #122 do not latch when the doors are closed, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All doors at the hospital must be verified at least monthly and appropriate documentation must be available upon request.

Based on a validation survey, observations made during the survey for life safety from fire it was determined that the facility failed to ensure that the emergency room and other wards have written plans for staff to follow with respect to their duties in the event of an emergency as required by the 2012 edition of the Life Safety Code of the NFPA Section 18.7.1.1.

Findings include:

1. No evidence was found from 5/9/17 through 5/12/17 from 9:00 am until 5:00 pm that emergency room personnel and ward personnel have a plan or assignments with specific tasks in the event of an emergency related to extinguisher use, circuit breaker shut off and oxygen valve shut off. All emergency personnel must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

2. No evacuation plans were found in the corridor near the admission department during the observational tour and in front of the elevators on 5/11/17 from 11:00 am through 12:00 noon.

Based on a validation survey, observations during the survey for Life safety from fire with the facility's Engineer, it was found that this facility does not comply with other Life Safety Code requirements not in CMS-2786-R related to the storage of oxygen tanks.

Findings include:

1.The parking area was observed on 5/10/17 at 1:50 pm and provided evidence that type H and type E oxygen cylinders are located in an area that is protected by a cyclone fence but do not has roof. The cylinders were placed directly on the cement floor and should be placed on another material that will prevent them from rusting as stated by the National Fire Protection Association (NFPA) 99 section 4-3.5.2.2 (Storage of cylinders and containers). Also, two gate doors used to enter this fenced area were found unlocked and accessible to non-authorized persons.