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Based on record review and staff interview, the facility did not ensure that functional tests of the battery powered emergency illumination equipment was provided in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.2.9.1 and 7.9.3. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

On 08/10/2022 at 9:54 am, record review revealed that there was no record of completion of the 90 minute functionality test of the emergency lights for the past 12 months.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff J.

Based on record review and interview, the facility did not inspect the kitchen range hood equipment in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.3.2.5 & 9.2.3; and NFPA 96 (2011 edition) Sections 11.4, 11.6, 11.6.1, 11.6.2, & 11.6.14. This deficient practice could affect an undetermined number of staff and visitors.

Findings include:

On 08/08/2022 at 2:15 PM, review of inspection records for the kitchen-hood exhaust system revealed that only one (1) semi-annual inspection for grease buildup was conducted over the past 12 months, on 03/08/2022.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff J

Based on record review and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 (2012 edition) Sections 19.3.5.1 & 9.7.5; NFPA 25 (2011 edition) Sections 5.1.1.2, 5.3.1.1.1.6, 5.3.1.2 & 14.2.1. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 08/10/2022 at 8:45 am, review of sprinkler system maintenance records revealed that the facility was not able to produce the 5-year sprinkler system inspection documentation of the check valve, gauges, and internal pipe inspection.

2. On 08/10/2022 at 8:48 am, review of sprinkler system maintenance records revealed that there was no record of the quarterly inspection for the second quarter of 2022.

3. On 08/10/2022 at 9:16 am, review of sprinkler system maintenance records revealed that there was no record of the 10-year dry head.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff R and Staff J.

Based on observation and interview, the facility did not maintain smoke barriers in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.7, 19.3.7.1, 19.3.7.3, 8.5, 8.5.2 and 8.5.6. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 08/10/2022 at 12:28 PM, observation at the smoke barrier wall between the east corridor of smoke zone 1 and smoke zone 2 revealed that the vertical corner above the ceiling was not sealed smoke tight with a listed fire/smoke system. Additionally, one wire rack penetrating the wall was not sealed above the wires with a listed fire/smoke system and one ¾" hole was not sealed.

2. On 08/10/2022 at 12:32 PM, observation at the smoke barrier between the west corridor of smoke zone 1 and smoke zone 2 revealed a 2" x 2" piece of gypsum board removed and not sealed by a listed system. Additionally, one vertical corner above the ceiling was not sealed smoke tight with a listed fire/smoke system.

These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff O and Staff R.

Based on record review and interview, the facility failed to inspect door assemblies at least annually with a written record of inspection and testing in accordance with NFPA 101 (2012 edition) sections 19.7.6, 4.6.12, 7.2.1.15, & 8.3.3, and NFPA 80 (2010 edition) section 5.2. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

On 08/08/2022 at 2:28 pm, record review revealed that the facility had no record that fire-rated door assemblies had been inspected or tested within the past 12 months.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff J.

Based on observation and interview, the facility did not provide a remote annunciator panel for the emergency generator in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.5, 19.5.1, 9.1; NFPA 110 (2010 edition) Section 5.6.6 and 5.6.5.2(4). This deficiency had the potential to affect all of the patients, as well as an undetermined number of staff and visitors.

Findings include:

On 08/10/2022 at 12:23 pm, observation at the Nurses' Station in Med-Surg revealed that the emergency generator annunciator panel was not located at a monitored location. The annunciator is in the Maintenance office which is not staffed 24 hours per day.

This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff J, Staff O and Staff R.

Based on record review and interview, the facility did not perform testing of the emergency generator in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.5.1 and 9.1.3; and NFPA 110 (2010 edition) Sections 8.4.1, and 8.4.2, and 8.4.5. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

On 08/08/2022 at 9:44 am, record review revealed that the running time of the generator was a total of 30 minutes for the test dates in September 2021 through January 2022. Time for the generator to get to operating temperatures and cool down of a minimum of 5 minutes was not included in the testing.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff J.