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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:

The east electrical room battery back-up emergency lighting did not illuminate when the test button was depressed.

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: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected areas in accordance with Life Safety Section 19.3.2.5. This deficient practice could affect all residents and staff in the main smoke compartment including the kitchen should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidence by the following.

Doors used as an opining protective for hazardous area requiring 1-hour separation between the main corridor and kitchen were not equipped with a self-closing device.

The Director of Maintenance acknowledged the area enclosures and door condition during a tour of the facility.

19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.

STANDARD is not met as evidenced by: During the tour and staff interview of the hospitals lab confirm that the facility failed to meet the Standards of NFPA 99 Health Care Facilities Code and the NFPA 45 Standard on Fire Protection for Laboratories Using Chemicals within the Labs Safety Procedures Plan. This deficient practice could affect all patients, staff and first responders should a fire emergency occur in the lab. This was evidence by the following;

The Lab did not have Material Safety Data Sheets (MSDS) for all hazardous material stored on site.

The GEO and Director of Maintenance acknowledged the lack of MSDS for all hazardous material in the lab during the tour of the facility.

NFPA 45 2011 Edition, Section A-6.6.3. An emergency response plan should be prepared and updated. The plan should be available for inspection by the AJH, upon reasonable notice. The following information should be included in the emergency plan.
(1) The type of emergency equipment available and its location
(2) A brief description of any testing or maintenance programs for the available emergency equipment
(3) An indication that hazard identification marking is provided for each storage area
(4) Location of posted emergency response procedures
(5) Material safety data sheets (MSDS) for all hazardous material stored on site
(6) A list of responsible personnel who are designated and trained to be liaison personnel for the fire department; these Individuals
should be knowledgeable in the site emergency response procedures and should aid the emergency responders with the following
functions:
(a) Pre-emergency planning
(b) Identifying where flammable, pyrophoric, oxidizing and toxic gases are located
(c) Accessing MSDSs
(7) A list of the types and quantities of compressed and liquefied gases normally at the facility

STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to provide a safe location to install Alcohol Base Hand Rub dispenser in accordance with Life Safety Code Chapter 19, Section 19.3.2.6(8). This deficient practice could affect all patient's, visitor's and staff should an electrical fault occur igniting the dispenser. This was evidence by the following.

During the walkthrough of the facility, with the Maintenance Director, alcohol based hand rub dispensers (ABHR) was located directly above an electrical card reader at the nurses' station.

The Maintenance Director acknowledged the (ABHR) location deficiency during a tour of the facility.

Life Safety Code 101, Section 19.3.2.6 Alcohol-Based Hand-Rub Dispensers shall be protected in accordance with 8.7.3, unless all of the following conditions are met:
(8) Dispensers shall not be installed in the following locations:
(a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source.
(b) To the side of an ignition source within a 1 in. (25 mm) horizontal distance from the ignition source.
(c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source

STANDARD is not met as evidenced by: Through record review and staff interview during the survey, the facility 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:

At the time of the survey, no documentation was available to indicate an itemized list of all devices on the Annual Testing of the fire alarm system.

The Director of Maintenance acknowledge the lack of required itemized list of all devices of the fire alarm system test report during the documentation review.

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.

1) No written documentation of the fire sprinkler control valves being inspected monthly.
2) No written documentation of the fire sprinkler gauges being inspected monthly.
3) Boiler room, a box fan was attached by wires to the fire sprinkler system piping.
4) Boiler room, power extension cord was attached to the fire sprinkler system piping.
5) East storage room IT cable attached to the fire sprinkler system piping.

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 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 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 in the service corridor and PT hall were not sealed to maintain the 30-minute fire resistance rating of the smoke barrier, as required.

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

This STANDARD is not met as evidenced by: Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.2 and 4.7. This deficient practice could affect all residents when staff are not trained in the emergency actions required during unusual condition that can occur in an actual emergency. This was evidenced by the following:

Fire drills are required to be conducted under varying conductions. Time of shifts is one of the conductions. Each shift is 8.5 hours long. Drills were conducted with in a 30-minute time frame from January, 2018 through February, 2019.
1) 1st shift three out of four fire drills in the past year cycle were conducted within a 10-minute time frame.
2) 1st shift no record of a fire drill being conducted in the third quarter.

The Director of Facility Maintenance and Maintenance Director acknowledge the conditions of fire drills deficiency during record review of the facility.

Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

Through observation during the survey, it was determined that the facility failed to provide metal containers with self-closing cover devices, into which ashtrays can be emptied, in areas where smoking is permitted in accordance NFPA 101Life Safety Code, Section 19.7.4 (4). This deficient practice could affect all residents in the permitted smoking areas if a fire was to occur in a non-combustible container. This was evidenced by the following.

All permitted smoking areas of the facility were not equipped with metal containers with self-closing cover devices in which ashtrays can be emptied into.

The Maintenance Director acknowledge the deficient conditions of smoking area during the tour of the facility.

NFPA 101Life Safety Code, Section 19.7.4 Smoking regulation shall be adopted and shall include not less than the following provisions:
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas
where smoking is permitted.

STANDARD is not met as evidenced by: Based on observation during the course testing the transfer switch on the generator it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 6 This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss. This was evidenced by the following.


1) At the time of the survey no records were available to verify testing and recording of lead acid batteries electrolyte specific gravity
testing in connection with the emergency power supply system (Emergency Generator) monthly.
2) Generator was not equipped with a manual stop station. 3-5.5.6 All Level I and Level 2 installation shall have a remote manual stop
station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located
elsewhere on the premises were the prime mover is located outside the building.
3) At the time of the survey no records were available to verify the three-year full load bank test for EPS I generator for four-hours.


The emergency power supply system deficiency item was discussed with the Director of Maintenance during the survey and again during the exit conference with the Hospital CEO.

NFPA 110, Section 6-4.1 Level I and Level EPSSs, including all appurtenant components, shall be inspected and shall be exercised under load at least monthly.