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The facility did not ensure that exit access is arranged so that exits are readily accessible at all times as required by the 2012 Life Safety Code.

On 05/11/23 at 1:00 PM, the surveyor while accompanied by facility administration observed the marked exit enclosure from the day center was being used to store facility equipment and had a coat hook assembly.

The facility did not ensure that a fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70," National Electrical Code" and NFPA 72, "National Fire Alarm Code" , and as required by the 2012 Life Safety Code

On 05/11/2023 at 9:30 AM, the surveyor was not provided with documentation to indicate that fire alarm system inspection and testing at the facility was being performed as required by "National Fire Alarm Code", section#14.4.5 & Table # 14.5 and as part of the facility's preventive maintenance program, i.e. The paperwork reviewed on the day of survey indicated that sensitivity testing had been conducted on 12/23/2021, the documentation failed to indicate the listed sensitivity range for the detectors and only listed pass/fail.

The facility did not ensure that linen and trash chutes, incinerators and trash collection rooms were protected as required by the referenced LSC.

On 05/11/23 at 11:30 AM, the surveyor along with facility administration observed that the trash chute door in the BHU failed to close and latch properly after it was released in order to provide the proper vertical fire and smoke protection between floors.

The facility did not ensure that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the 2012 Life Safety Code.

On 05/11/2023 at 10:00 AM, the surveyor was not provided with documentation that fire drills were conducted for the 2nd ,3rd & 4th quarters on the 3rd shift of 2022 and the 2nd shift of the 4th quarter of 2022, and documentation was not provided to indicate that the facility conducted a 3rd shift fire drill in the 1st quarter of 2023. i.e. the facility provided the dates of the missing drills with no documentation, logs or signature sheets with times and who was present.

The facility did not ensure that the piped in medical gas systems are in compliance with 2012 NFPA 99 "Health Care Facilities Code" 5.2.14.

On 05/11/23 at 10:00 AM, the surveyor was not provided with documentation that indicated that the piped in medical gas system had been inspected as part of an established testing, maintenance and operational program for Oxygen Medical Gas, Medical Air Compress and Vacuum System and equipment as required by NFPA 99.

The facility did not ensure that additional testing of receptacles in patient care rooms was being conducted, as required by section # 6.3.4.1.3 of 2012 NFPA 99, "Health Care Facilities Code".

On 05/11/23 at 9:30 AM the surveyor was not provided with documentation to indicate that electrical receptacles throughout the facility in patient care rooms were being tested at intervals not exceeding 12 months-or at intervals defined by documented performance data, as required by section # 6.3.4.1.3 of NFPA 99, "Health Care Facilities Code"..

The facility did not ensure that transferring of oxygen was in compliance with the requirements of NFPA 99 "Health Care Facilities Code".

On 05/11/23 at 10:00 AM, The surveyor along with the facility maintenance observed that the facility was filling portable liquid oxygen reservoirs inside the loading dock area, and the loading dock lacked sprinkler protection and signs warning staff of the filling operations