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Based on record review and interview made in the presence of the plant manager on 01-06-2020 it was determined that the facility failed to develop and maintain a comprehensive emergency preparedness program that must be reviewed, and updated at least annually.

This deficiency affected 1 of 1 required emergency preparedness program.

Findings include:
1-During the record review it was discovered that the facility did not develop and maintain a comprehensive emergency preparedness program in accordance with Title 42, Code of Federal Regulations, 485.625.

Based upon observations made in the presence of the plant manager on 01-06-2020, 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 5.2, NFPA 105

Based upon observations made in the presence of the administrator and plant manager on 01-06-2020 it was determined that the facility did not provide an emergency lighting system in accordance with NFPA 101 19.2.9.1 , 20.2.9existing and 7.9)

This deficiency affected all emergency lights.

Findings include:
During the record review it was observed that the facility failed to provide the documentation of the identification and annual and monthly testing of the emergency lights with battery backup, in accordance with NFPA 101 7.9.3.

Based upon observations made in the presence of the plant manager on 01-06-2020, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1, 19.3.2.1.1 through 19.3.2.1.5(18.3.2.1)

This deficiency affected 1 of 3 smoke compartments

Findings include:
1- During the facility tour in soiled utility room #1049 a penetration was observed that was approximately 3 inch by 10 inch in size around a HVAC duct. Hazardous areas shall be fire and smoke separated from other sections of the facility in accordance with NFPA 101 19.3.2.1.

Based upon observations made during the record review made in the presence of the plant manager on 01-06-2020, 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 several required tests.

Findings include:
1- 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, the 08-2019 was not completed. 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
2- During the record review portion of the survey the facility failed to produce documentation of two riser tamper switch tests, this finding was confirmed with the plant manager. 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)

Based upon observations made during the record review with the plant manager on 01-06-2020, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 101, 9.7.5.

This deficiency affected all of the fire sprinkler system.

Findings include:
1-During the record review it was discover that the automatic sprinkler and standpipe systems had not been inspected, tested, and maintained in the last 12 months in accordance with NFPA 25 5.2, TABLE 5.1.1.2. These finding were verified with the plant manager.

Based upon observations made during the record review with the plant manager on 01-06-2020, 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 19.7.1.4. Through 19.7.1.7.

This deficiency affected 1 of 12 fire drills.

Findings include:
During the record review the facility failed to provide documentation of 2 of the required fire drills, the missing drill's was the fourth quarter drills, Several of the other drills had drill dates but did not have the times that the 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 19.7.1.4. Through 19.7.1.7.

Based upon observations made in the presence of the plant manager on 01-06-2020, 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 10 of the stored cylinders.

Findings include:
1-During the facility tour with the plant manager in the ER triage room it was discovered that there was 1 E size cylinder of oxygen that was not secured and not in accordance with NFPA 99 5.1.3.3.2 (7)
2- During the facility tour with the plant manager in the central supply room it was discovered that there was 3 E size cylinders of oxygen and 3 D size cylinders that were not secured and there was also 3 cylinders of various sizes that were on a storage shelf and they were not secured and not in accordance with NFPA 99 5.1.3.3.2(7)

Based upon observations made during the record review made in the presence of the plant manager on 01-06-2020, it was determined that the facility did not maintain gas system in accordance with NFPA 99 5.1.14.2.3.

This deficiency affected the medical vacuum system.

Findings include:
During the record review the facility failed to provide documentation of the vacuum system is inspected annually and tested as part of a maintenance program and not in accordance with NFPA 99 5.1.14

Based upon observations made in the presence of the plant manager on 01-06-2020, it was determined that the facility did not maintain the essential systems remote annunciator in accordance with NFPA 101 19.5.1.3, NFPA 99 6.4.1.1.17, 6.4.1.1.17.

This deficiency affected 1 of the several generator maintenance test required.

Findings include:
1-During the building tour it was observed that the facilities remote annunciator was located in the House keeping supply room and not in a location that is readily observable by operating personal at a regular work station. The plant manager stated that there was no other generator annunciator panels. A remote annunciator that has storage battery power, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station.

Based upon record review made in the presence of the plant manager on 01-06-2020, 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., 8.4.1

This deficiency affected several 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 record review the facility failed to provide documentation that the facility had inspected the emergency generator set weekly and exercised under load 30 minutes 12 times a year, the plant manager verified these findings, they were not in accordance with NFPA 99 6.4.4, 6.5.4, 6.6.4 and NFPA 110 8.4.2.3
3-During the record review it was discover that the facility failed to supply the annual load test of the emergency generator in accordance with and NFPA 110 7.13, 8.4.2.3