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STANDARD is not met as evidenced by: Based on observation and staff interviews of the emergency lighting, the facility failed to maintain the battery-powered emergency lights accordance with 7.9.3 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power. This was evidenced by the following:

No documentation was available during record review of the facility required testing of the battery-powered emergency lighting system at 30 day intervals for not less than 30 seconds or annually for not less than 1 ½ hours

Maintenance acknowledge the required testing of the emergency lighting during the tour of the facility.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

facility failed to maintain the battery-powered emergency lights accordance with 7.9.3 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power. This was evidenced by the following:

1.No documentation was available during record review of the facility required testing of the battery-powered emergency lighting system at 30 day intervals for not less than 30 seconds or annually for not less than 1 ½ hours.

2.The battery-powered emergency lighting was non-functional at the:
(a)Basement room
(b)Fire exit second floor
(c)Emergency Transfer Switch room

The Maintenance Director acknowledge the required testing of the emergency lighting during the tour of the facility.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

STANDARD is not met as evidenced by: Exit signs are required wherever the path of egress is not obvious. These must be illuminated either internally or externally and under both normal and emergency conditions. As stated in Life Safety Code Sections 18.2.10.1 and 19.2.10.1. Based on observation and staff interview during the survey, it was determined that the facility failed to maintain marking of means of egress in accordance with Life Safety Section 7.10. This deficient practice could affect all patients, staff and visitors if code compliant exit signage is not provided for building egress.

Exit signs would not illuminate when the test button was pressed:
1.)East and West Lobby Door
2.)Main Entrance (x2)
3.)West Exit Door

Maintenance personnel acknowledge the lack of exit signage condition during the tour of the facility.

Life Safety Code 7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use, unless otherwise provided
in 7.8.1.2.2.

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 marking of means of egress in accordance with Life Safety Section 7.10. This deficient practice could affect all residents, staff and visitors in the area if code compliant exit signage is not provided for building egress. This was evidence by the following.

Facility failed to provide proper exit signage in the main corridors, directional arrows were pointing in the wrong direction.

Maintenance acknowledge the lack of exit signage condition during the tour of the facility.

Life Safety Code 19.2.10.1. Means of egress shall have signs in accordance with section 7.10. The directional indicator shall be located outside of the Exit legend, not less than 3/8 in. (1cm) from any letter. The directional indicator shall be of a chevron type. The directional indicator shall be identifiable as a directional indicator at a distance of 40 ft. (12.2m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width and stroke. The directional indicator shall be located at the end of the sign for the direction indicated.

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 marking of means of egress in accordance with Life Safety Section 7.10. This deficient practice could affect all residents, staff and visitors in the area if code compliant exit signage is not provided for building egress. This was evidence by the following.

Facility failed to provide proper exit signage.
1.Corridor 1600 exit signage no directional arrows.
2.Corridor 1900 exit signage no directional arrows.

The Director of Maintenance acknowledge the lack of exit signage condition during the tour of the facility.

Life Safety Code 19.2.10.1. Means of egress shall have signs in accordance with section 7.10. The directional indicator shall be located outside of the Exit legend, not less than 3/8 in. (1cm) from any letter. The directional indicator shall be of a chevron type. The directional indicator shall be identifiable as a directional indicator at a distance of 40 ft. (12.2m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width and stroke. The directional indicator shall be located at the end of the sign for the direction indicated.

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 residents and staff in the main smoke compartment should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidence by the following.

Hazardous area corridor doors were not arranged to be self-closing, as required
The Medical Records Storage Room is larger than 50 square feet and contains storage of flammable and combustibles storage and is considered as a hazardous area, the door was not equipped with a self-closing device, as required.

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

Life Safety Code Section 19.3.2.1 requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting construction. Doors installed to protect hazardous areas must be self-closing or automatic closing.

failed to inspect and test the fire alarm system per NFPA 72 and 2012 Life Safety Code 101. Failure to maintain and test the fire alarm system has the potential to harm all occupants, staff and visitor within the facility if the fire alarm system failed to operate if a fire was to occur. This was evidenced by the following:

1.Annual Fire Testing report noted batteries at the main panel fail test and needs replaced. At the time of the survey batteries have not been replaced.
2. Elevator fire doors on the first floor main lobby failed to release from the magnets on activation of fire alarm.

The Director of Maintenance acknowledge the lack of testing of the fire alarm system in the past year during the tour of the facility.

2012 Life Safety Code 101 section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

STANDARD is not met as evidenced by: Through record review during the survey, it was determined that the facility failed to establish a written fire watch procedure in accordance with 2012 NFPA 101 Life Safety Code, Section 9.6.1.6. This deficient practice could affect all residents, staff and visitors should the fire alarm or fire sprinkler system was out of service and a fire was to occur. This was evidence by the following.

The facility failed to establish a written fire watch procedure in the event the fire alarm system was out of service for more than 4 hours in a 24 period.

The Maintenance Director acknowledged the lack of a written Fire Watch program deficiency during record review of the facility.

2012 Life Safety Code 101 section 9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following.

Fire Suppression system back-flow preventer fail certification and has not been repaired at the time of the survey.

The Director of Maintenance acknowledge the lack of maintenance of the automatic sprinkler system deficiency during record review of the facility.

NFPA 101Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

STANDARD is not met as evidenced by: Through record review during the survey, it was determined that the facility failed to establish a written fire watch procedure in accordance with 2012 NFPA 101 Life Safety Code, Section 9.7.5. This deficient practice could affect all residents, staff and visitors should the fire alarm or fire sprinkler system was out of service and a fire was to occur. This was evidence by the following.

The facility failed to establish a written fire watch procedure in the event the fire sprinkler system was out of service for more than 10 hours in a 24 period.

The Maintenance Director acknowledged the lack of a written Fire Watch program deficiency during record review of the facility.

2012 Life Safety 101 Section 19.5.1, 9.7.5, 15.5.2 NFPA Where a required fire sprinkler system is out of service for more than 10 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain all portable fire extinguishers as required by NFPA 10 Chapter 4. This deficient practice could affect all residents, staff and visitors should the portable fire extinguishers fail to operate effectively due to non-code compliant maintenance. This was evidence by the following.

At the time of the survey no documentation or records that all fire extinguishers through-out the facility were subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

The Maintenance Director acknowledge the lack of maintenance and inspection requirements of the portable fire extinguishers deficiency during record review of the facility.

Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire Extinguishers

STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain all portable fire extinguishers as required by NFPA 10 Chapter 4. This deficient practice could affect all residents, staff and visitors should the portable fire extinguishers fail to operate effectively due to non-code compliant maintenance. This was evidence by the following.

Fire extinguisher in the fire sprinkler riser room has not been inspect since 2015.

Maintenance personnel acknowledge the lack of maintenance and inspection requirements of the portable fire extinguishers deficiency during record review of the facility.

Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire Extinguishers

STANDARD is not met as evidenced by: Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors. This was evidenced by the following:

1.)Fire Door Main Lobby were not maintained to close and positively latch as required.

2.)Doors contained excessive gaps in excess of 1/2 -inch between the top of the door and door frames and would not resist the passage of smoke.
a.PT office door
b. Exam Room 8
c.Mechanical Room

Maintenance personnel acknowledge the corridor door condition during the facility tour.

The Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with the means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Doors must be unobstructed from closing and positively latching into the door frame. Section 19.3.6.3.1, Exception #2 requires that corridor doors installed within sprinklered protected smoke compartments be constructed to resist the passage of smoke.

STANDARD is not met as evidenced by: Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors. This was evidenced by the following:

Corridor doors were not maintained to close and positively latch, as required. Doors to IT, Autoclave closet, EVS closet and elevator service room would not close and latch into the door frame without excessive force and would not resist the passage of smoke.

The Director of Maintenance acknowledge the corridor door condition during the facility tour.

The Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with the means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Doors must be unobstructed from closing and positively latching into the door frame. Section 19.3.6.3.1, Exception #2 requires that corridor doors installed within sprinklered protected smoke compartments be constructed to resist the passage of smoke.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the fire resistance rating of smoke barrier walls were not maintained in accordance with Life Safety Code Section 19.3.7.3 This deficient practice could affect all residents in all smoke compartment by allowing the spread of fire and smoke to the adjoining compartments. This was evidenced by the following:

Unsealed penetrations at smoke barrier walls were not sealed to maintain the 30-minute fire resistance rating of the smoke barrier, as required.
1.Electrical room 2703 penetration above door.
2. Mechanical room 1419 penetrations in ceiling.
3.Fire door 2519 above grid.

The Maintenance Director acknowledge the penetrations during a tour of the facility.

Life Safety Code Section 19.3.7.3 requires that the smoke barrier wall be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than ½ hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces. Section 8-3.6.1 requires, in part, that the space between piping penetrations

STANDARD is not met as evidenced by: Based on record review and discussion with staff during the course of the survey, it was determined that the facility failed to contain all required elements of the fire safety plan in accordance with the Life Safety Code, Section 19.7.2 and 19.7.2.3. This deficient practice could affect all residents and staff within the facility should a fire emergency was to occur. This was evidenced by the following:

During review of the facility records, with the Maintenance Director, no written Fire Safety Plan was available for review.

The Director of Maintenance acknowledge the lack of a required fire plan during the facility record review.

The Life Safety Code Section 19.7.2.3 requires that; a written health care occupancy fire safety plan shall provide for the following:
(1) Use of Alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and buildings for evacuation
(8) Extinguishment of fire