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Through record review and observation during the survey, January 10 and 11, 2017, it was determined that the facility failed to maintain the emergency lighting systems.

During the walk through of the facility, with the Maintenance Director the battery-powered emergency light (frogeye light) located in the mechanical room D124, would not illuminate with the test button depressed. This deficiency was orrected during the survey.


This deficiency could effect one of four smoke compartments in building D

Through observation during the survey, conducted January 10 and 11, 2017 it was determined that the facility failed to maintain the fire alarm system in accordance with NFPA 72.

During a walk through of the facility with the Maintenance Director, the annual fire alarm testing documentation did not contain a complete listing of all devices tested as required by NFPA 72 14.6.2.4

The fire alarm testing documentation also did not include the required fire damper testing.


This deficiency could effect the enttire facility

Through observation during the survey, conducted January 10 and 11, 2017 it was determined that the facility failed to maintain the fire alarm system in accordance with NFPA 72.

During a walk through of the facility with the Maintenance Director, the annual fire alarm testing documentation did not contain a complete listing of all devices tested as required by NFPA 72 14.6.2.4

The fire alarm testing documentation also did not include the required fire damper testing.

This deficiency could effect the entire facility.

Through observation during the survey, January 10 and 11 2017 , it was determined that the facility failed to install an automatic sprinkler system per NFPA 13.

During the walk through of the facility, with the Maintenance Director;
The sprinkler riser gauges were dated as 2011. These gauges are to be replaced or re-calibrated every five years.


This deficiency could effect the entire facility.

Through observation during the survey, January 10 and 11, 2017 , it was determined that the facility failed to install and maintain an automatic sprinkler system per NFPA 13.

During the walk through of the facility, with the Maintenance Director, the sprinkler riser gauges were dated 2011. These gauges are to be replaced or recalibrated every five years.


This deficiency could effect the entire facility.

Through observation during the survey, January 10 and 11, 2017 , it was determined the facility failed to maintain the doors to the corridor.

During the walk through of the facility with the Maintenance Director; door 133 would not latch into the frame. This deficiency was corrected during the survey.

This deficiency could effect one of four smoke compartments in building D.

Through record review and discussions with the staff during the survey, January 10 and 11, 2017, it was determined that the facility failed to conduct fire drills on each shift quarterly.
 
During the review of the facility records, with the Maintenance Director, fire drill documentation was not available for first nine months of 2016.


Thsi deficiency could effect the entire facility

Through record review and discussions with the staff during the survey, January 10 and 11, 2017, it was determined that the facility failed to conduct fire drills on each shift quarterly.
 
During the review of the facility records, with the Maintenance Director, fire drill documentation was not available for first six months of 2016.


This deficiency could effect the entire facility