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The facility did not ensure that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the referenced LSC.

On 03/15/16 at 10:30 AM, the surveyor was not provided with documentation by the Director of Facilities that fire drills were conducted for the 1st quarter of 2016 and the drills for the 3rd shift 2015 were all silent drills conducted after 6:00 AM. The facility was utilizing the exception in the LSC 19.7.1.2 for silent fire drills between the hours of 9:00 PM through 6:00 AM not in compliance with the exception i.e. the drills were conducted at 6:05 and 6:10 AM.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC and NFPA 25 section 5.3.1.1.

On 03/15/16 at 10:20 AM, the surveyor was not provided with documentation by the Director of Facilities to indicate that the Dry Pendant sprinkler heads in service for ten (10) years, heads dated 1998, had been replaced or tested by a recognized testing laboratory acceptable to the authority having jurisdiction for field testing as required by NFPA 25 section 5.3.1.1.

The facility did not ensure that the design, installation and use of its commercial cooking equipment was in accordance with NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations as required by the Life Safety Code.

On 03/15/16 at 10:30 AM, The surveyor was not provided with documentation by Director of Facilities to indicate that the Kitchen hood extinguishment system had been inspected within the past six (6) months (last inspection date: 06/15/15).

The facility did not ensure that piped in medical gas systems are in compliance with NFPA 99, 8-6.2.4.5.

On 03/15/16 at 10:30AM, the surveyor was not provided with documentation by the Director of Facilities that indicated that the piped in medical gas system had been inspected as part of an established testing, maintenance and operational program for Oxygen Medical Gas, Medical Air Compress and Vacuum System and equipment as required by NFPA 99.

The facility did not ensure that Emergency and Standby Power Systems were being inspected and maintained as required in NFPA 110 " Standard for Emergency and Standby Power Systems " .

On 03/15/16 at 10:30 AM, The surveyor was not provided with documentation by the Director of Facilities that the facilities emergency generator was being maintained as required by NFPA 110 " Standard for Emergency and Standby Power Systems " Chapter 6 section 1.1 i.e. no Level 2 maintenance was conducted in calendar year 2015 or 2016.

The facility did not ensure that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the referenced LSC.

On 03/15/16 at 10:30 AM, the surveyor was not provided with documentation by the Director of Facilities that fire drills were conducted for the 1st quarter of 2016 and the drills for the 3rd shift 2015 were all silent drills conducted after 6:00 AM. The facility was utilizing the exception in the LSC 19.7.1.2 for silent fire drills between the hours of 9:00 PM through 6:00 AM not in compliance with the exception i.e. the drills were conducted at 6:05 and 6:10 AM.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC and NFPA 25 section 5.3.1.1.

On 03/15/16 at 10:20 AM, the surveyor was not provided with documentation by the Director of Facilities to indicate that the Dry Pendant sprinkler heads in service for ten (10) years, heads dated 1998, had been replaced or tested by a recognized testing laboratory acceptable to the authority having jurisdiction for field testing as required by NFPA 25 section 5.3.1.1.

The facility did not ensure that the design, installation and use of its commercial cooking equipment was in accordance with NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations as required by the Life Safety Code.

On 03/15/16 at 10:30 AM, The surveyor was not provided with documentation by Director of Facilities to indicate that the Kitchen hood extinguishment system had been inspected within the past six (6) months (last inspection date: 06/15/15).

The facility did not ensure that piped in medical gas systems are in compliance with NFPA 99, 8-6.2.4.5.

On 03/15/16 at 10:30AM, the surveyor was not provided with documentation by the Director of Facilities that indicated that the piped in medical gas system had been inspected as part of an established testing, maintenance and operational program for Oxygen Medical Gas, Medical Air Compress and Vacuum System and equipment as required by NFPA 99.

The facility did not ensure that Emergency and Standby Power Systems were being inspected and maintained as required in NFPA 110 " Standard for Emergency and Standby Power Systems " .

On 03/15/16 at 10:30 AM, The surveyor was not provided with documentation by the Director of Facilities that the facilities emergency generator was being maintained as required by NFPA 110 " Standard for Emergency and Standby Power Systems " Chapter 6 section 1.1 i.e. no Level 2 maintenance was conducted in calendar year 2015 or 2016.