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Based upon observations made in the presence of the plant manager on 11-06-2019, it was determined that the facility did not continuously maintain the means of egress and exits to the public way at all times in accordance with NFPA 101: 20.2.1, 7.1.10.1

This deficiency affected all fire door openings.

Findings include:
1-During the record review it was discovered that the facility did not test and maintain the annual inspections of fire doors in accordance with NFPA 80, NFPA 25

Based upon record review made in the presence of the plant manager on 11-06-2019 it was determined that the facility did not provide an emergency lighting system in accordance with NFPA 101 19.2.9.1.

This deficiency affected 2 of 2 emergency lights.

Findings include:
During the record review the facility failed to provide documentation that the emergency lights annually or monthly and was not being tested and was not in accordance with NFPA 101 7.9.3.

Based upon record review made in the presence of the plant manager on 11-06-2019 it was determined that the facility had not conducted the annual testing of the 1 fire window located in the dietary department and not in accordance with NFPA 101 19.3 and NFPA 80 5.2.5. , 5.2.14

This deficiency affected 1 of 1 fire windows.

Findings include:
During the facility tour it was observed that the fire rated roll down window in the kitchen serving area had not been tested annually in accordance with NFPA 80 5.2.5. , 5.2.14, 5.2 this finding was verified by the facility manager

Based upon observations made in the presence of the plant manager on 11-06-2019, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 101 19.3.4.4, 9.6.5. And NFPA 72 Table 14.4.2.2.

This deficiency affected all smoke compartments.

Findings include:
1-During the record review the facility failed to provide the testing documentation that the (Emergency control functions) smoke damper operations had been tested annually with the initiating device that activates the damper. All inspections and testing shall be documented, indicating the location of the fire, fire smoke dampers, date(s) of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected in accordance with NFPA 80 19.3.4., NFPA 72 Table 14.4.2.2 and not in accordance with NFPA 19.5.2.1, 9.2 and NFPA 72 Table 14.4.2.2

Based upon record review made in the presence of the plant manager on 11-06-2019, it was determined that the facility did not maintain the fire alarm system in accordance with NFPA 101 9.6.1.3, 9.6.1.5.; and NFPA 72.

This deficiency affected 1 of 2 tests.

Findings include:
1-During the record review portion of the survey the facility documentation that one of the two riser tamper switch tested semiannually. Valve supervisory alarm devices shall be tested semiannually in accordance with NFPA 101 19.3.5.1, 9.7.5. And NFPA 72 table 14.4.5. (15.l-1)
2- During the record review portion of the survey the facility it was observed that the documentation for the annual smoke detector testing was incomplete, the facility director stated that their fire alarm testing is tested quarterly breaking the facility up into 4 sections, only one of the sections had been tested in the last 12 months, the facility manager called the vendor and they stated that the testing was not done for the three missing quarters and was not in compliance with NFPA 72 9.7.5, 9.7.7, 9.7.8, and NFPA 25.
3- During the record review the facility failed to provide documentation that the fire alarm control panel batteries had been tested under load two times in the last year. Batteries need to be tested semiannually in accordance with NFPA 101 20.3.4.1. & 9.6.1.1.; and NFPA 72 Table 14.4.5

Based upon observations made in the presence of the plant manager on 11-06-2019, it was determined that the facility did not maintain portable fire extinguishers in accordance with NFPA 10 and NFPA 101 19.3.5.12.

This deficiency affected 1 HFC 227 extinguisher system.

Findings include:

During the record review the facility failed to provide a documentation indicating that the HFC 227 extinguisher system in the IS room had been annually inspected, the tag indicated that it was expired in 2018 ". In addition to the required tag or label, a permanent file record should be kept for each fire extinguisher. This file record should include the following information, as applicable:
(1) Maintenance date and the name of the person and the agency performing the maintenance
(2) Date of the last recharge and the name of the person and the agency performing the recharge
(3) Hydrostatic retest date and the name of the person and the agency performing the hydrostatic test
(4) Description of dents remaining after passing of the hydrostatic test
(5) Date of the 6-year maintenance for stored-pressure dry chemical and halogenated agent types.
In accordance with NFPA 101 19.3.5.12 and NFPA 10 7.3.3, 7.2.2

Based upon observations made in the presence of the plant manager on 11-06-2019, it was determined that the facility did not maintain the fire resistance rating in accordance with NFPA 101 19.3.7., 8.5.3

The deficiency affected 1 of several fire/smoke compartments.

Findings include:
1-During the tour of the facility it was observed that the Fire barrier wall above the fire doors at the corridor by the nurses station to the registration area had unsealed penetrations 8"x2" and not in accordance with NFPA 101 19.3.7.3, 8.5.
2- During the tour of the facility it was observed that the Fire barrier wall above the fire doors at the corridor by the nurses station to the emergency room entrance area had unsealed penetrations 2"x2" and not in accordance with NFPA 101 19.3.7.3, 8.5.

Based upon observations made in the presence of the plant manager on 011-06-2019, it was determined that the facility did not maintain the door openings in smoke barriers to have at least a 20 minute fire protective rating. The doors shall be self-closing or automatic closing in accordance with NFPA 101 19.3.7.8.

This deficiency affected 2 of 6 smoke compartments.

Findings include:
1- During the facility tour it was discovered that the corridor door into the clean side of the laundry room was being held open with a bungee cord and not in compliance with NFPA 19.3.7.8, 8.5.4
2- During the facility tour it was discovered that the corridor door into the dirty side of the laundry room was being held open as the door was dragging on the floor and stuck in the open position and not in compliance with NFPA 19.3.7.8, 8.5.4
3- During the facility tour it was discovered that the Anastasia work room was converted to a storage room and did not have a door closure and not in compliance with NFPA 19.3.7.8, 8.5.4
4- During the facility tour it was discovered that the central processing rooms rated door had 6 penetrations in the door and not in compliance with NFPA 19.3.7.8, 8.5.4

Based upon made in the presence of the plant manager on 11-06-2019, it was determined that the facility did not install or maintain the buildings heating, ventilating and air conditioning systems in accordance with NFPA 101 19.5.2.1 and 9.2., NFPA 72 Table 14.4.2.2

This deficiency affected all fire/smoke dampers.

Findings include:
During the record review the facility fail to provide documentation that the fusible link fire dampers were maintained within the last four years, All inspections and testing shall be documented, indicating the location of the fire, fire smoke dampers, date(s) of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected in accordance with NFPA 101 19.5.2.1; 9.2.1; NFPA 90A 3-4.7.,NFPA 80 19.3.4,19.4.9,19.4.9.1,19.4.10

Based upon observations made during the record review in the presence of the plant manager on 11-06-2019, it was determined that the facility did not conduct fire drills held at unexpected times under varying conditions at least quarterly on each shift in accordance with NFPA 101 21.7.1.4. Through 21.7.1.7.

This deficiency affected 9 of 12 required fire drills.

Findings include:
During the record review the facility failed to provide documentation that the 1st, 2nd and 3rd quarter fire drills were conducted. Fire drills shall be held at unexpected time under varying conditions at least quarterly on each shift in accordance with NFPA 101 21.7.1.4. Through 21.7.1.7,

Based upon observations made in the presence of the plant manager on 11-06-2019, it was determined that the facility did not test the Line Isolation Monitors in accordance with NFPA 99 6.3.4.1.4, 6.3.3.3.2

The deficiency affected the line isolation monitor.

Findings include:
1-During the document review it discovered that there was no tests being performed on the Line Isolation Monitor circuits. .Line Isolation Monitors shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6).
For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. And not in accordance with NFPA 99 6.3.4.1.4

Based upon record review made in the presence of the plant manager on 11-06-2019, it was determined that the facility did not maintain, inspect and exercise the facilities emergency generator set in accordance with NFPA 99 6.4.4 and NFPA 110 8.4.2.3.

This deficiency affected one of the required tests.

Findings include:
1-During the record review the facility failed to provide documentation that the Maintenance of the generator batteries had been conducted. Maintenance of Lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted in accordance with NFPA 110 8.3, 8.3.7
2- During the facility tour it was observed that the generator did not have a remote manual stop located outside of the enclosure. All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building in accordance with NFPA 99 6.5.4 and NFPA 110 5.6.5.6.

Based upon observations made in the presence of the plant manager on 11-06-2019, it was determined that the facility did not use power strips in accordance with NFPA 101 19.5.1 and 9.1.2

This deficiency affected 2 of 3 smoke compartments.

Findings include:

1-During the facility tour power strips were observed to be "daisy chained" at the ER nurses station. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling in accordance with NFPA 70 110-3b,
2--During the facility tour 3 power strips were observed to be "daisy chained" in the IS closet. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling in accordance with NFPA 70 110-3b,

Based upon observations made in the presence of the plant manager on 11-06-2019, it was determined that the facility did not maintain medical gas storage in accordance with NFPA 99 5.1.3.3.2.

This deficiency affected 4 of the stored cylinders.

Findings include:
1-During the facility tour with the facility manager it was discovered that there was 3 CO2 cylinders in the nutrition room that was not secured and not in accordance with NFPA 99 5.1.3.3.2 (7)
2- During the facility tour with the facility manager it was discovered that there was 1 H cylinder in the lab micro biology room that was not secured and not in accordance with NFPA 995.1.3.3.2(7)