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Based on observations and interview with the Maintenance Director, the facility failed to maintain safe and reliable exit egress per NFPA 101 (2012) 19.2.1. and 7.5.1.1. All exit doors must be maintained in proper operational condition. Reliable egress is essential to the safety of all persons within the facility in an emergency situation.

Findings include:
During the facility tour with Maintenance Director on 02/15/2017 starting at 1:00 pm it was observed that the automatic exit doors in the Emergency Room are not opening once power has been shut off to door.
These findings were verified by the Maintenance Director at the times observed.

Based on facility records and interview with the maintenance director, the facility failed to ensure that all battery emergency lights were tested for 30 seconds monthly and 90 minutes annually in accordance with NFPA 101 (2012 edition) 19.2.9., 7.9., and NFPA 99 (2012 edition) 6.3.2.2.11. This could delay or deny exiting the facility in an emergency.

The findings include:
During documentation review on 02/15/2017 starting at 10:30 a.m. revealed the facility was unable to produce documentation to show the 90 minute inspection and tested of the emergency lights in the facility was completed.

These findings were verified by the maintenance director at the times observed.

Based on observation and interview with the maintenance director, the facility failed to identify doors that serve as exits and doors that do not serve as exits per NPFA 101 (2012 edition) 19.2.10.1 and 7.10. This in the event of an emergency could cause confusion to occupants trying to exit the building.

The findings Include:
During the facility tour with maintenance director on 02/15/2017 starting at 12:00 pm, it was observed that the Exit Sign at the Operation Room hall door is missing the left chevron indicator.

These findings were verified by the maintenance director at the times observed.

Based on observation and interview with the maintenance director, the facility failed to provide inspection, maintenance and testing of the fire sprinkler system in accordance with NFPA 25 (2011 edition) 5.2.1.1.1. Failure to inspect, maintain, and test system components could result in the system failing to perform as designed.

Findings include:
During the facility tour with maintenance director on 02/15/2017 starting at 11:45 am the following were observed:
1) Sprinkler head in Room 118 bathroom is missing escutcheon.
2) Sprinkler head in Room 114 closet is missing escutcheon.
3) Sprinkler head in Room 113 is corroded.
4) Sprinkler head in Room 104 is covered with dust.
5) Sprinkler head in Room 102 bathroom is missing escutcheon.
6) Sprinkler head in Room 100 closet is missing escutcheon.
7) Sprinkler head in kitchen service hall outside the storage room is dirty.
8) Sprinkler heads throughout the kitchen are corroded.
9) Facilities 5 year internal sprinkler testing has not been completed.

These findings were verified by the maintenance director at the times observed.

Based on observation and interview with the Maintenance Director, the facility failed to maintain proper maintenance of corridor doors in accordance with NFPA 101 (2012 edition) 19.3.6.3. This could allow fire, smoke and fire gasses to enter the compartment which would impede or deny the exiting of occupants in an emergency and result in harm to the occupants from the dangers of the emergency situation.

The findings Include:
During the facility tour with the Maintenance Director on 02/15/2017 starting at 10:30 am, the following was observed:
1) Patient Room 110 door not latching when closed.
2) Chapel door not latching when closed.
3) Emergency Room Staff Lounge door not latching when closed.

These findings were verified by the maintenance director at the times observed.

Based on document review and interview with the maintenance director, the facility failed to maintain documentation on the exercising of the main and feeder breakers per NFPA 70 (2012) 9.1.2. Not exercising as required by the manufacture can lead to corrosion among other issues which can cause delay or the inability to transfer power in a time of emergency. This could result in loss of power to the facility in the event of a simultaneous failure of the local utility and the emergency generator thereby endangering the patients and occupants of the facility.

Findings include:
During the document review on 02/15/2017 at 10:00 am, it was found that there was no documentation to show that the main and feeder circuit breakers were inspected annually as required by manufactures recommendations.

These findings were verified by the maintenance director at the times observed.