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Based on observations, the facility failed to maintain combustible decoration in accordance with NFPA Life Safety Code 101 (00) section 19.7.5.4. The failure to treat and maintain the combustible decorations throughout the facility in accordance with NFPA Life Safety Code 101 (00) could allow smoke and fire to rapidly migrate through the corridors and negatively affect the egress capability in the event of an emergency for residents, visitors and staff of the facility.

Findings include:

On facility tour between 9:30 AM on 03/04/2015 and 4:30 PM on 03/05/2015, observations reveled that the facility has combustible decorative wood logs located in the 4th floor in the corridor by the exit stairwell.


This deficient practice was verified by the Director of Maintenance.

Based on observations and interview with staff, the facility has failed to ensure that the operating locations are equipped with battery backup emergency lights in accordance with NFPA 99 (99) Section 3.1. This deficient practice could affect patients, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:


On facility tour between 9:30 AM on 03/04/2015 and 4:30 PM on 03/05/2015, observations revealed that the ASC operating rooms were not equipped with battery backup emergency lights in accordance with NFPA 99 (99) Section 3.1.


This deficient practice was verified by the Director of Maintenance.

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. 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 affecting patients, staff, and visitors of the facility.


Findings include:


On facility tour between 9:30 AM on 03/04/2015 and 4:30 PM on 03/05/2015, observations revealed that there were numerous smoke detectors located in multiple locations throughout the facility that were installed within 36 inches of HVAC diffusers.


This deficient practice was verified by the Director of Maintenance.

Based on observations, the facility failed to maintain combustible decoration in accordance with NFPA Life Safety Code 101 (00) section 19.7.5.4. The failure to treat and maintain the combustible decorations throughout the facility in accordance with NFPA Life Safety Code 101 (00) could allow smoke and fire to rapidly migrate through the corridors and negatively affect the egress capability in the event of an emergency for residents, visitors and staff of the facility.

Findings include:

On facility tour between 9:30 AM on 03/04/2015 and 4:30 PM on 03/05/2015, observations reveled that the facility has combustible decorative wood logs located in the 4th floor in the corridor by the exit stairwell.


This deficient practice was verified by the Director of Maintenance.

Based on observations and interview with staff, the facility has failed to ensure that the operating locations are equipped with battery backup emergency lights in accordance with NFPA 99 (99) Section 3.1. This deficient practice could affect patients, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:


On facility tour between 9:30 AM on 03/04/2015 and 4:30 PM on 03/05/2015, observations revealed that the ASC operating rooms were not equipped with battery backup emergency lights in accordance with NFPA 99 (99) Section 3.1.


This deficient practice was verified by the Director of Maintenance.