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Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager and Maintenance Staff that the facility failed to test and maintain fire alarm in accordance with NFPA 72 for the entire building. This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72 and NFPA 25). Findings include, but are not limited to:
1. On 10/27/2016, during the revisit of the facility between 9:00 a.m. and 12:30 p.m., the documentation presented by the facility to the surveyor showed that the third party vendor for the facility conducted an annual fire alarm system test and the third party vendor did not completed the test as directed in NFPA 72. The third party vendor did not test any of the Heat Detectors or Sprinkler Flow switches. The third party vendor only tested 1 of 4 Duct Detectors and 1 of 2 Sprinkler Supervisory Switches.
2. On 10/27/2016, during the revisit of the facility between 9:00 a.m. and 12:30 p.m., monthly and quarterly testing and maintenance was not being performed as required in NFPA 72.
Surveyor was accompanied by the Environmental Services Manager and Maintenance Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to ensure the automatic sprinkler and standpipe systems were continuously maintained, inspected and tested in a reliable operating condition for the entire building. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12, NFPA 25, NFPA 13). Findings include, but are not limited to:
1. On 10/27/2016, during the revisit of the facility between 9:00 a.m. and 12:30 p.m., there was no documentation showing required weekly and quarterly maintenance and testing on the facilities automatic sprinkler system.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to ensure the sprinkler system is continuously maintained & in reliable operating condition for the entire building. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:
1. On 10/27/2016, during the revisit of the facility between 9:00 a.m. and 12:30 p.m., documentation presented to the surveyor from the facility showed that the forward flow test that was performed did not meet the demand of the facilities automatic sprinkler system which was a minimum of 500 gpm at 20 psi as the system was a pipe schedule system and not a calculated suppression system.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

Based on record review and interviews it was determined through on-going dialog with the Environmental Services Manager, EMS Coordinator and Maintenance Staff that the facility failed to properly maintain the generator or other alternate power source and associated equipment affecting the entire facility. This resulted in the potential for the lack of emergency electrical power during an emergency event (LSC 4.6.12.1, NFPA 110, NFPA 99, NFPA 70, and NFPA 111). Findings include, but are not limited to:
1. On 10/27/2016, during the revisit of the facility between 9:00 a.m. and 12:30 p.m., the facility did not have documentation of the required 3yr. 4-hour load bank test at a minimum of 80% of the nameplate. Documentation presented was only a 2-hour load bank test.
Surveyor was accompanied by the Environmental Services Manager, EMS Coordinator and Maintenance Staff who acknowledged the existence of these conditions.

Based on the observations and interview during the survey, it was determined through on-going dialog with the Environmental Services Manager and Maintenance Staff that the facility failed to install and protect alcohol based hand rub (ABHR) dispensers away from sources of ignition for ED of the building. This resulted in the potential for injury to residents/patients and staff (LSC 19.3.2.6, 8.7.3.1, 42 CFR 403, 418, 460, 482, 483, and 485, NFPA 30). Findings include, but are not limited to:
1. On 11/8/2016, during the revisit of the facility between 9:00 a.m. and 12:30 p.m., there was a alcohol based hand rub (ABHR) dispenser that was installed above and an electrical light switch within the ED Exam Room.
Surveyor was accompanied by the Environmental Services Manager and Maintenance Staff who acknowledged the existence of these conditions.