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Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not meeting all requirements of NFPA 96 regarding fire protection for the cooking facilities.

The findings include:

1) During the survey at approximately 1250 hours on November 9, 2016 through observation of the physical environment and confirmed through interview with the Director of Plant Operations it was determined that the facility failed to maintain the kitchen hood extinguishing and ventilating system as required by not having the kitchen hood filter elements installed as required. There was observed to be an approximately 6" gap between filter elements as installed, which would allow direct heat exposure into the ventilation duct.

2) During the survey at approximately 1250 hours on November 9, 2016 through observation of the physical environment and confirmed through interview with the Director of Plant Operations, it was determined that the facility failed to maintain the main kitchen hood extinguishing system as required by not having the manual activation device installed as required. The manual activation device (and the building fire alarm system manual pull station)was obstructed from being readily visible in the path of egress by a wheeled bread rack (NFPA 96, 2011 ed., Chap. 10.5.1).

3) During the survey at approximately 1310 hours on November 9, 2016 through observation of the physical environment and confirmed through interview with the Director of Plant Operations, it was determined that the facility failed to maintain the Cafeteria kitchen hood extinguishing system as required by not having the manual activation device installed as required. No manual activation device is located in the path of egress as required (NFPA 96, 2011 ed., Chap. 10.5.1). All NFPA 96 required hoods shall meet the requirements for fire extinguishing equipment therein, including Chapter 10.3-Simultaneous Operation and 10.5-Manual Activation.

Failure to provide or maintain the required NFPA 96 fire protection equipment has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not providing a smoke detection system in all areas of the building as required.

The findings include:

During the survey on November 9, 2016 at approximately 1320 hours, it was observed and confirmed through interview with the Director of Plant Operations that in the Rosenberg Building Outpatient Lobby area there is a fire alarm power supply mounted on the corridor wall. It was observed and confirmed that there is no smoke detection in this area as required.

All areas of the health care facility must be fire alarm system protected in accordance with NFPA 101, NFPA 72, and CMS requirements. Failure to protect any area as required has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based observation of the physical environment, review of the facility's records, and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining all fire alarm systems as required by NFPA 72.

The findings include:

During the survey on November 9, 2016 between 0930 hours and 1130 hours it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the Director of Plant Operations that the NFPA 72 required sensitivity test of the facility's fire alarm smoke detectors has not been performed as required.

The failure to maintain the facility fire alarm system as required could lead to improper operation of the system in the event of an emergency thereby promoting harm to occupants of the facility.

Based observation of the physical environment, review of the facility's records, and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining all water based suppression systems as required by NFPA 25.

The findings include:

1) During the survey on November 9, 2016 between 0930 hours and 1130 hours, it was determined through a review of the facility's records, observation of the physical environment, and confirmed through interview with the Director of Plant Operations that the NFPA 25 required annual inspection, test, and maintenance of the facility's standpipe system(s) has not been performed as required.

2) During the survey on November 9, 2016 at approximately 1205 hours it was determined through observation of the physical environment and confirmed through interview with the Director of Plant Operations that in the West Penthouse of the Main Hospital Building there was spray on fireproofing material coating the automatic sprinkler piping and sprinkler heads.

3) During the survey on November 9, 2016 at approximately 1330 hours it was determined through observation of the physical environment and confirmed through interview with the Director of Plant Operations that in the Mechanical Room (#R-1-120) of the Rosenberg Building there was paint on the deflector of the automatic sprinkler head.

The failure to maintain the water based suppression systems as required could lead to improper operation of the systems in the event of an emergency thereby promoting harm to occupants of the facility.

Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not fulfilling all portable fire extinguisher installation requirements of NFPA 10.

The findings include:

During the survey on November 9, 2016 at approximately 1250 hours it was determined through observation of the physical environment and confirmed through interview with the Director of Plant Operations that the required class "K" portable fire extinguisher for the Cafeteria was not installed as required. There is no class "K" portable fire extinguisher in the Cafeteria cooking area, along the path of egress, or readily available to this cooking area as required (NFPA 10, 2010 ed., Chapter 6.1.3-Placement).

Failure to properly install and maintain portable fire extinguishers as required has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not providing walls throughout the facility that are fire resistant as required.

The findings include:

During the survey on November 9, 2016 at approximately 1210 hours it was determined through observation of the physical environment and confirmed through interview with the Director of Plant Operations that the Pharmacy on the 2nd floor of the Main Hospital Building was expanded into an area that was previously used as storage closets accessed off the main corridor. Where the interior Pharmacy partition was built out to this corridor the storage closet door assemblies were left in place. The door assemblies are not required to meet equivalent FRR as corridor walls.

Failure to properly construct and maintain partitions as required has the potential to promote harm to occupants of the facility in the event of a fire.

Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining all electrical utility equipment and installation requirements of NFPA 70.

The findings include:

During the survey on November 9, 2016 at approximately 1300 hours it was determined through observation of the physical environment and confirmed through interview with the Director of Plant Operations that in the Kitchen Storage Room there are combustible items (styrofoam cups, platters, cardboard boxes, etc) stored on shelving units less than 36" from an 80 gallon electric water heater.

Failure to properly maintain storage in utility areas as required has the potential to promote harm to occupants of the facility in the event of a fire.

NFPA 30, 2012 edition, Flammable and Combustible Liquids Code, Chapter 6 Fire and Explosion Prevention. NFPA 704, 2012 edition, Standard System for Identification of the Hazards of Materials for Emergency Response, Chapter 9 Identification of Materials

Based on observation of the physical environment and interview with facility staff it was determined that facility staff failed to provide a safe and hazard free environment by allowing flammable or combustible liquids to be stored without required identification or markings.

The findings include:

During the survey on November 9, 2016 at approximately 1330 hours it was observed and confirmed through interview with the Director of Plant operations that the 10,000 gallon above ground diesel fuel storage tank for the emergency generator does not display the required NFPA 704 identification or the required "No Smoking" signs.

The failure to properly identify combustible liquids storage as required has the potential to promote harm to occupants of the building.

Based on review of facility documents and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not fulfilling all emergency electrical systems inspection and testing requirements of NFPA 99 and 110.

The findings include:

During the survey between 0930 hours and 1100 hours on November 9, 2016 it was determined through review of the facility's documents and confirmed through interview with the Director of Plant Operations that the emergency electrical system for the building is not documented as having been inspected and tested as required by NFPA 99 and 110 during the required monthly test under load or the required weekly inspection. The emergency electrical system test records show that during the monthly tests under load the percent of the generator output per the name plate rating is not recorded, therefore the facility is not able to document if the requirement to achieve 30% or more of the rating is met. Also, during the weekly inspections the only data being recorded is percent of fuel supply available. All inspection and testing requirements of NFPA 110, 2010 ed., Chapter 8 shall be performed and documented.

Failure to properly test the emergency electrical system as required has the potential to promote harm to occupants of the facility in the event of a fire or other emergency.

Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not providing medical gas storage locations in the building as required.

The findings include:

During the survey on November 9, 2016 at approximately 1215 hours it was observed and confirmed through interview with the Director of Plant Operations that the Oxygen Storage Room on the second floor of the Main Hospital does not display the required precautionary sign (NFPA 99, 2012 ed., Chap. 11.3.4.2). The only sign identifying this oxygen storage room is a "OXYGEN" placard above the door.

All medical gas storage rooms in the health care facility must be in accordance with NFPA 101, NFPA 99, and CMS requirements. Failure to identify or protect any area as required has the potential to promote harm to occupants of the facility in the event of a fire in this area.