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Based on observations and an interview with staff, the facility has failed to ensure that emergency lighting has been tested and maintained in accordance with the NFPA 101 "The Life Safety Code" 2012 edition (LSC) section 7.9.3. This deficient practice could affect the patients, as well as an undetermined number of staff, and visitors in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 10:00 a.m. to 3:00 p.m. on 08/29/2017, observation during a review of all available testing and maintenance documentation and an interview with the Maintenance Supervisor revealed that the facility has not completed 2 of 12 monthly 30 second test of the battery operated emergency lights.


This deficient condition was verified by the Maintenance Supervisor.

Based on observations and staff interview, it was revealed that the facility has failed to provide proper protection for 1 of several hazardous areas located throughout the facility in accordance with NFPA 101 "The Life Safety Code" 2012 edition (LSC) section 19.3.2.1. This deficient conditions could in the event of a fire, allow smoke and flames to spread throughout the effected corridors and areas making them untenable, which could negatively affect 4 of 10 patients as well as an undetermined number of staff, and visitors.


Findings include:

On facility tour between 10:00 a.m. to 3:00 p.m. on 08/29/2017, observations revealed that the IT data/storage room 2156 had a penetration around the red conduit passing through the wall.


This deficient condition was verified by the Maintenance Supervisor.

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2012 NFPA 101, "The Life Safety Code" Sections 19.3.4.1 and 9.6, as well as 2010 NFPA 72, "National Fire Alarm and Signaling Code" sections 29.8.3.4. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affect 10 of 10 patients, as well as an undetermined number of staff, and visitors.


Findings include:


On facility tour between 10:00 a.m. to 3:00 p.m. on 08/29/2017, the following deficient conditions were found affecting the fire alarm system:

1. There is a horn/strobe device that is hanging by a section of clear plastic tubing that is attached to the sprinkler pipe that is located in the laundry room.

2. There is a heat detector that is hanging by its wires from the ceiling located in the elevator equipment room.


This deficient condition was verified by the Maintenance Supervisor.

Based on observation and staff interview, the facility has failed to provide a complete and current facility Risk Assessment in accordance with the NFPA 99 "Health Care Facilities Code" 2012 edition section 4.1. This deficient practice could affect 10 of 10 patients, as well as an undetermined number of staff, and visitors.


Findings include:

On facility tour between 10:00 a.m. to 3:00 p.m. on 08/29/2017, during the documentation review and an interview with the Maintenance Supervisor it was revealed that the facility could not provide any risk assessment documenting or proof that the risk assessment had been completed at the time of the inspection.


This deficient condition was verified by a Maintenance Supervisor.

Based on observations and staff interview, that the electrical testing and maintenance was not maintained in accordance with NFPA 99 Standards for Health Care Facilities 2012 edition, section 6.3.4. This could negatively affect 10 of 10 patients as well as an undetermined number of staff, and visitors to the facility.

Findings include:

On facility tour between 10:00 a.m. to 3:00 p.m. on 08/29/2017, during a records review and an interview with the Maintenance Supervisor, the facility could not provide any documentation for the completion of the annual electrical outlet inspection and testing for the electrical outlets located in the patient rooms located throughout the facility.


This deficient condition was verified by a Maintenance Supervisor.

Based on observations and staff interview, that the oxygen storage room was not maintained in accordance with NFPA 99 Standards for Health Care Facilities 2012 section 5.1.3.3..2 and NFPA 70 National Electrical Code 2011 edition. This deficient practice could create an oxygen enriched atmosphere that could contribute to rapid fire growth. This could negatively affect 10 of 10 patients as well as an undetermined number of staff, and visitors to the facility.

Findings include:

On facility tour between 10:00 a.m. to 3:00 p.m. on 08/29/2017, observations revealed that the light switch that is located in the oxygen storage room is not protected from physical damage since it has been installed below 5 feet from the finished floor and it is not equipped with any protective device or cover.


This deficient condition was verified by a Maintenance Supervisor.