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A. Based on observation and interview, the provider failed to:
*Provide emergency exit discharge lighting at one of multiple exits (Original 1921 building west stair exit discharge). Findings include:

1. Observation at 10:30 a.m. on 6/20/17 revealed a stairwell exit on the west end of the original 1921 building. The building was greater than or equal to four stories and required emergency lighting for exit egress. Lighting at the exit discharge was provided by exterior light fixtures from the neighboring building. That building was not provided with an emergency power source. Failure of normal power would have left the exit discharge in darkness.

Interview with the director of plant operations at the time of the above observation confirmed that condition. He indicated he believed adequate lighting was provided and was unaware the lighting was required to be tied to emergency power.

B. Based on observation and interview, the provider failed to:
*Provide vertical separation between the ground floor and basement for one of one entrance in the Avera Therapy Mitchell clinic located at 200 E Havens Ave. Findings include:

1. Observation at 12:30 p.m. on 6/20/17 revealed the door to the basement was a residential type wood panel door incapable of providing the required sixty minute fire separation. Interview with the clinic maintenance director at the above time indicated that door was part of the original construction.

Based on record review and interview, the provider failed to ensure proper records were maintained for quarterly flow tests conducted by plant operations staff. Findings include:

1. Record review at 8:30 a.m. on 6/20/17 of the water based fire sprinkler revealed incomplete records for the quarterly flow test. Proper records shall include the test results for each alarm device installed on the system. The records indicted dates the quarterly flow tests were conducted but did not provide any test results for comparison of current and past results.

Interview with the plant operations supervisor at the time of the above record review confirmed that condition. He indicated he was not aware test results were required for each alarm device.

Based on observation and interview, the provider failed to ensure the reception staff responsible for monitoring the fire alarm annunciator, gas and vacuum master alarm annunciator, and generator annunciator panels were familiar with emergency alarm functions. Findings include:

1. Observation at 1:45 p.m. on 6/20/17 revealed the fire alarm annunciator panel, gas and vacuum alarm annunciator, and the generator annunciator panel located at the reception desk. Interview with the director of plant operations revealed reception staff were responsible for alerting emergency personnel and plant operations of issues and alarms presented by the annunciator panels.

Interview with the reception staff at the time of the above observation revealed they were not familiar with the different alarm conditions that might be observed on the panels. Alarm monitoring should have been done by authorized staff competent of the alarm and trouble signals to ensure proper response was provided in emergency situations.