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STANDARD is not met as evidenced by: Based on record review and staff interviews of the emergency lighting, the battery-powered emergency lights have not been monthly and annually tested in accordance with 7.9.3 and 19.2.9.1. This deficient practice could affect all patients 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 annual testing of the battery-powered emergency lighting system at 30 day intervals for not less than 30 seconds or required annual testing of the battery-powered emergency lighting system for not less than 1 ½ hours.

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 record review and staff interviews of the emergency lighting, the battery-powered emergency lights have not been monthly and annually tested in 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 annual testing of the battery-powered emergency lighting system at 30 day intervals for not less than 30 seconds or required annual testing of the battery-powered emergency lighting system for not less than 1 ½ hours.

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.

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 19.2.10.1. 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 Same-Day Clinic area if code compliant exit signage is not provided for building egress. This was evidence by the following.

Facility failed to maintain exit signage through-out the building all exit lighted signage were not illuminated to maintain marking of means of egress in accordance with Life Safety Section 7.10.

The Maintenance Director acknowledge the lack of exit signage maintenance 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.

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 19.2.10.1. 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 Same-Day Clinic area if code compliant exit signage is not provided for building egress. This was evidence by the following.

Facility failed to provide exit signs in the Same-Day Clinic to maintain marking of means of egress in accordance with Life Safety Section 7.10.

The Maintenance Director 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 observation and discussion during the tour of the facility, it was determined the facility failed to install and maintain fire rated doors per NFPA 101 2012 Edition Chapter 8 Section 8.3.3 paragraph 8.3.4.4. Failure to maintain fire rated door and assemblies in hazardous areas has the potential to harm all occupants, staff and visitor in the building if the fire rated doors failed to operate if a fire was to occur. This was evidence by the following.

Three doors from the Lab, considered a hazardous area, opening in to the corridor were not protected by approved, listed, labeled fire door assemblies and their accompanying hardware, including all frames, closing devices with requirements of NFPA 80 Standard for Fire Doors and Other Opening Protectives.

TheMaintenance Director acknowledged the condition of doors and assemblies during the tour of the facility.

8.3.3 Fire Doors and Windows.
8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.

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 19.3.2.7(6). This deficient practice could affect all residents should an electrical fault occur igniting the dispenser.

During the walkthrough of the facility, Maintenance Director, alcohol based hand rub dispensers (ABHR) was installed directly above electrical outlets in the main corridor.

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

Life Safety Code Chapter 19, Section 19.3.2.7(6) "The dispensers shall not be installed over or directly adjacent to an ignition source."

STANDARD is not met as evidenced by: Through a review of the records and discussion during the survey, it was determined the facility failed to inspect and test the fire alarm system per NFPA 101, Chapter 9 (Section 9.6 Paragraph 9.6.1.4) and NFPA 72, (Chapter 7, Paragraph 7-1.2.2). Failure to maintain and test the fire alarm system has the potential to harm all occupants, staff and visitor in the build if the fire alarm system failed to operate if a fire was to occur. This was evidenced by the following:

During the review of the records, with the Maintenance Director, documentation was not available to verify the annual testing of the fire alarm system or sensitivity testing of the smoke detectors per NFPA 101 2012 Edition 19.3.4.1, 9.6.1.3 and NFPA 72 7-3 and 7-3.2.1.

The Maintenance Director acknowledged the condition of testing the fire alarm system during the record review.

NFPA 14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and
telephone number
(6) Name, address, and representative of approving agency (ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer ' s published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device
abandoned in place)

NFPA 7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside
its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

STANDARD is not met as evidenced by: Based on observation, staff interview and, 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.

The facility failed to maintain the automatic sprinkler system; Located in the kitchen walk-in cooler the sprinkler head has appeared to be leaking covering the working parts of the sprinkler head with rust.

The Maintenance Director 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: 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 and staff interview during the tour of the facility, 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:

Smoke barrier wall penetrations were not sealed to maintain the 30-minute fire resistance rating of the smoke barrier, as required. The Chiller room smoke barrier wall was observed to have unsealed penetrations in the gypsum board.

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 and the smoke barrier wall be filled with a material capable of maintaining the 30- minute fire resistance rating of the barrier.

Smoke barriers shall be constructed to provide at least a one half hour fire resistance rating and construction in accordance with 8.3 Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames. 8.3, 19.3.7.3, 19.3.7.5

This STANDARD is not met as evidenced by: Based on observation and staff interview during the tour of the facility, 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 occupants in the building by allowing the spread of fire and smoke to the adjoining compartments. This was evidenced by the following:

Smoke barrier wall penetrations were not sealed to maintain the 30-minute fire resistance rating of the smoke barrier, as required. The furnace room ceiling was observed to have unsealed 2 ' x 2 ' opening in the gypsum board.

The Maintenance Director acknowledge the unsealed opening 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 and the smoke barrier wall be filled with a material capable of maintaining the 30- minute fire resistance rating of the barrier.

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 electrical equipment in accordance with National Fire Protection Association 70, National Electrical Code. This deficient practice could affect all residents within the hospital due to increased potential hazards of electrical fire. This was evidence by the following:

The facility failed to maintain electrical equipment.
During the walk-through of the facility, two (2) electrical j-box covers were missing exposing energized electrical connections in the maintenance office.

The Maintenance Director acknowledged the electrical hazard during a tour of the facility.

NFPA 70, National Electrical Code Article 370-25. Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

STANDARD is not met as evidenced by: Through observation during the tour of the facility, it was determined the facility failed to maintain the Heating, Ventilating, and Air-Conditioning Systems in accordance with Section 9.2, 19.5.2.1.9.2, NFPA 90A and 19.5.2.2. 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:

The facility failed to maintain the Heating, Ventilating, and Air-Conditioning Systems. Laundry Dryer combustible air-intake vent was covered and sealed off with plywood not allowing the gas fired dryers to take air for combustion directly from the outside.

The vent deficiency was discussed with the Maintenance Director during the survey and again during the exit conference with the Administrator.

Life Safety Code Section 19.5.2.2: Any heating device other than a central heating plant shall be designed and installed so that combustible material will not be ignited by the device or its appurtenances. If fuel-fired, such heating devices shall be chimney connected or vent connected, shall take air for combustion directly from the outside, and shall be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area. Any heating device shall have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperature or ignition failure.