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Through document review and staff interview it was determined the facility failed to maintain Means of Egress requirements in accordance with NFPA 101; evidenced by:

The Access control Egress door located next to the old kitchen, and equipped with a magnetic locking device failed to de-energize upon activation of the fire alarm system. This affected the left leaf only, and reduced the egress capacity by half.

This deficiency affected all occupants of the facility including residents, staff, and visitors, and was discussed with the Administrator and the Maintenance Director during the exit conference.

Through document review and staff interview, it was determined the facility failed to maintain Means of Egress requirements in accordance with NFPA 101; evidenced by:

The self-closing fire-rated door at the top of the West Stair enclosure was observed to be propped open with a brown plastic wedge-shaped door stop. This was corrected during the survey.

This deficiency affected the occupants of the third floor limited to staff, and visitors, and was discussed with the Facility Administrator and Maintenance Director during the exit conference.

Through document review and staff interview it was determined the facility failed to maintain Means of Egress requirements in accordance with NFPA 101; evidenced by:

An open annulus, where sprinkler pipe penetrated the 1-hr rated stair enclosure was observed in the East Stairwell.

This deficiency affected all occupants of the facility including residents, staff, and visitors, and was discussed with the Administrator and the Maintenance Director during the exit conference.

Through document review and staff interview it was determined the facility failed to maintain Means of Egress requirements in accordance with NFPA 101 and NFPA 110; evidenced by:

A) The required annual 90-minute testing of battery-powered emergency lighting was not performed, according to staff interview with maintenance staff.

B) One battery-powered Emergency Lighting device located in the Physical Therapy offices did not illuminate when tested.

C) Two battery-powered Emergency Lighting devices in the main storage room, located in the basement, did not illuminate when tested.

D) The battery-powered Emergency Lighting device in the ATS room, did not illuminate when tested.

This deficiency affected all occupants of the facility including residents, staff, and visitors, and was discussed with the Administrator and the Maintenance Director during the exit conference.

Through Document review, Observation and Staff interview, it was determined the facility failed to maintain Protection requirements in accordance with NFPA 101; evidenced by:

A) Hazardous areas were observed to not have the required smoke resistant enclosure in a fully-sprinklered building by having observable holes in the gypsum board in the following locations: Boiler Room, Oxygen manifold room,

B) Hazardous areas were observed to not have the required smoke resistant enclosure in a fully-sprinklered building by missing self-closing devices on doors in the following locations: The supply room in the in-patient ward, Room 53, the Tree of Sharing Storage room,

This deficiency affected the occupants of one smoke compartment, including residents, staff, and visitors, and was discussed with the Facility Administrator and Maintenance Director during the exit conference.

Through document review and staff interview, it was determined the facility failed to maintain Protection requirements in accordance with NFPA 101 and NFPA 72; evidenced by:

A) No smoke detector sensitivity testing was conducted in the past two years, according to document review and staff interview with maintenance staff.

B) One Audio/visual notification device, located in the main storage room, located in the basement, was observed to be hanging form its wires and not properly installed.

C) Visual notification devices (strobes) continued to flash when the fire alarm system was placed in Silence, where NFPA 72 requires the visual notification to cease when the audible notification is silenced.

This deficiency affected all occupants of the facility including residents, staff, and visitors, and was discussed with the Facility Administrator and Maintenance Director during the exit conference.

Through document review and staff interview it was determined the facility failed to maintain Protection requirements in accordance with NFPA 101 and NFPA 13; evidenced by:

A) The linen closet located in the in-patient ward was observed to have no sprinkler head in the closet.

B) The IT server room, located in the basement, was observed to have no fire suppression system installed in the server room.

This deficiency affected all occupants of the facility including residents, staff, and visitors, and was discussed with the Administrator and the Maintenance Director during the exit conference.

Through document review and staff interview, it was determined the facility failed to maintain Protection requirements in accordance with NFPA 101 and NFPA 25; evidenced by:

A) In the third floor air handling room, data cables were observed to be attached to the fire sprinkler piping and hangers where nothing is permitted to be hung from, or attached to, fire sprinkler system components.

B) The fire sprinkler head located in the ER decontamination room was observed to have paint on the frangible bulb.

This deficiency affected all occupants of the facility including residents, staff, and visitors, and was discussed with the Facility Administrator and Maintenance Director during the exit conference.

Through document review and staff interview, it was determined the facility failed to maintain Protection requirements in accordance with NFPA 101 and NFPA 10; evidenced by:

A) The portable fire extinguisher located in the third floor air handling room was observed to be placed onto of a computer CPU instead of mounted or in a cabinet as required.

B) The portable fire extinguishers located in the IT Office and in the corridor outside of the HR office were observed to be mounted greater than 60 inches above the finished floor.

C) The portable fire Extinguisher located in the Boiler Room was observed to have a charge below the serviceable level. This was corrected during the survey.

This deficiency affected all occupants of the facility including residents, staff, and visitors, and was discussed with the Facility Administrator and Maintenance Director during the exit conference.

Through Document review, Observation and Staff interview, it was determined the facility failed to maintain Protection requirements in accordance with NFPA 101; evidenced by:

The ED Sleep Room, RN Sleep Room and Provider Sleep rooms were observed to have gaps at the tops of corridor doors which would allow the passage of smoke and other products of combustion.

This deficiency affected the occupants of one smoke compartment, including residents, staff, and visitors, and was discussed with the Facility Administrator and Maintenance Director during the exit conference.

Through document review and staff interview, it was determined the facility failed to maintain Protectives requirements in accordance with NFPA 101 and NFPA 80; evidenced by:

A) No annual fire door inspection was conducted within the last year, according to document review and staff interview with maintenance staff. B) The Smoke Barrier Door located outside Patient Room 103 failed to automatically close upon activation of the Fire Alarm system.

This deficiency affected all occupants of the facility including residents, staff, and visitors, and was discussed with the Facility Administrator and Maintenance Director during the exit conference.

Through document review and staff interview, it was determined the facility failed to maintain Operating Features requirements in accordance with NFPA 101; evidenced by:

Fire Drills were not conducted once per quarter on each shift, determined by document review, which indicated that three of four quarters in 2017 did not have a Night Shift (1900-0700) fire drill.

This deficiency affected all occupants of the facility including residents, staff, and visitors, and was discussed with the Facility Administrator and Maintenance Director during the exit conference.

Through document review and staff interview, it was determined the facility failed to maintain Operating Features requirements in accordance with NFPA 101; evidenced by:

The facility's smoking policy states that it is a Non-Smoking campus and that no smoking is permitted anywhere on campus, and a commercial butt can was observed to located just outside of the Medical Gas Room and adjacent to the fuel-fired generator, creating a de facto smoking area.

This deficiency affected all occupants of the facility including residents, staff, and visitors, and was discussed with the Facility Administrator and Maintenance Director during the exit conference.

Through document review and staff interview, it was determined the facility failed to maintain Operating Features requirements in accordance with NFPA 101; evidenced by:

A portable electric space heater was observed to be in use at the reception desk in the lobby. The oil-filled portable space heater did not meet he requirements for use in a Health Care Facility in accordance with Paragraph 19.7.8 of the 2012 edition of NFPA 101, Life Safety Code.

This deficiency affected the occupants of one smoke compartment, including patients, staff, and visitors, and was discussed with the Facility Administrator and Maintenance Director during the exit conference.