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Through a review of the records and discussion during the survey on October 19, 2021, it was determined the facility failed to inspect and test the fire alarm system per NFPA 101, Chapter 9 (Section 9.6 Paragraph 9.6.1.5) and NFPA 72, (Chapter 7, Paragraph 7-1.2.2). The following evidenced this:

1) Annual fire alarm inspection report shows deficiencies with batteries. No documentation for deficiency correction.
2) No documentation for semi-annual fire alarm battery load test.
3) Detector outside of ED located within 36" of air diffuser.
4) Detector in Pre-op Anti room located within 36" of air diffuser.

The Fire Alarm System deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within all smoke compartments; items were discussed during the survey and again during the exit conference.

Maintenance Director acknowledged the condition of testing the fire alarm system during the record review.

Based on observation, staff interview and record review on October 19, 2021, it was determined that the facility failed to maintain all portable fire extinguishers as required by Life Safety 101 and NFPA 10. The following evidenced this:

1) Fire extinguisher located near patient rm 5 is mounted greater than 5' from finished floor.

Maintenance Director acknowledged the lack of maintenance and inspection requirements of the portable fire extinguishers deficiency during record review of the facility.

The fire extinguisher deficiencies have the potential to affect all room occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference.

Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire Extinguishers.

Based on observation and staff interview during the course of the survey conducted on October 19, 2021, it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 19.3.7.3 including 8.5. The following evidenced this:

1) Above ceiling in OR near locker room and OR 5 have penetrations in conduit ends
2) Above ceiling in OR near locker room and OR 5 have "blow out" patch in drywall, not leaving a even surface from stud to stud.

Maintenance Director acknowledged the deficiency during a tour of the facility.

The smoke barrier deficiency has the potential to affect all occupants, who might include staff and visitors in associated compartments; items were discussed during the survey and again during the exit conference.

Based on observation and staff interview during the survey on October 19, 2021, it was determined that the facility failed to maintain electrical equipment in accordance with NFPA 70, NFPA 99 Ch 10 and NFPA 101. This was evidenced by the following:

1) Lab has multiple fridges plugged into powerstrips.
2) Pre-op has fridge plugged into powerstrip.

The electrical equipment deficiency has the potential to affect all occupants, who might include staff, residents and visitors within all associated smoke compartments; items were discussed during the survey and again during the exit conference.