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STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with Life Safety Section 19.3.2.1. This deficient practice could affect all patients ' and staff in the smoke compartments should there be smoke and heat transfer between the hazard area and other portions of the building. This was evidence by the following.

Hazardous area corridor doors were not arranged to be self-closing in the Laundry room and Lab as required per Life Safety Code Section 19.3.2.1.3.

The Maintenance Director acknowledged the hazardous area enclosures and door condition during a tour of the facility.

Life Safety Code Section 19.3.2.1.3 requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting construction. Doors installed to protect hazardous areas shall be self-closing or automatic closing.

STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to provide a safe location to install Alcohol Base Hand Rub dispenser in accordance with Life Safety Code Chapter 19, Section 19.3.2.6(8). This deficient practice could affect all patient ' s, visitor ' s and staff should an electrical fault occur igniting the dispenser. This was evidence by the following.

During the walkthrough of the facility, with the Maintenance Director, alcohol based hand rub dispensers (ABHR) was located directly above an electrical light switch in patient ' s rooms, 11,12,13,14.

The Maintenance Director acknowledged the (ABHR) location deficiency during a tour of the facility.

Life Safety Code 101, Section 19.3.2.6 Alcohol-Based Hand-Rub Dispensers shall be protected in accordance with 8.7.3, unless all of the following conditions are met:

(8) Dispensers shall not be installed in the following locations:
(a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source.
(b) To the side of an ignition source within a 1 in. (25 mm) horizontal distance from the ignition source.
(c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source

This Standard is not meet as evidenced by; The facility failed to meet the minimum construction requirements in accordance with NFPA 101, 19.1.6 Minimum Construction Requirements. This deficient practice could affect all patient ' s, visitors and staff should fire occur within the facility.

During the tour of the facility it was determined the facility is a two-story Type II (000) structure with no fire sprinkler protection in accordance with NFPA 101,19.1.6.2, Construction Type limitation, a facility found to be a Type II (000) structure must be protected throughout by an automatic sprinkler system, and may be no more than two (2) stories in height.

The Director of Maintenance acknowledge the automatic sprinkler system requirements throughout the building during the tour of the facility.

Life Safety Code Section 19.1.6 Health Care Occupancies shall be limited to the construction types specified in Table 191.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7.

STANDARD is not met as evidenced by: Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.2 and 4.7. This deficient practice could affect patient ' s when staff are not trained in the emergency actions required during unusual condition that can occur in an actual emergency. This was evidenced by the following:

Fire drills are required to be conducted on each shift quarterly, the facility failed to conduct a fire drill on the second shift in the third quarter.

The Director of Maintenance acknowledge the conditions of fire drills deficiency during record review of the facility.

Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.