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Based on document review, the facility failed to maintain the emergency lighting so that during a power outage, means of egress and critical care areas will remain illuminated. This condition could affect all staff, patients and visitors resulting in failure of illumination under emergency conditions.

The finding is:

A. On 06/13/16 at 1:00pm while accompanied by the D.F. and H.M., document review determined that a written log of the 30 day testing for battery powered emergency lighting was not provided. There is no written documentation of testing for the 12 month period of 2015/2016. This condition does not comply with 18.2.9.1 and 7.9.3.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on document review, the facility failed to maintain the emergency generator so that during a power outage the generator will operate as necessary. This condition could affect all staff, patients and visitors resulting in failure of the generator under emergency conditions going unnoticed by staff.

The finding is:

A. On 06/13/16 at 12:30pm while accompanied by the D.F. and H.M., document review determined that a written log of weekly visual inspections was not provided for the 12 month period of 2015/2016 in order to comply with NFPA 110, 6-4.2.

Based on document review, the facility failed to maintain the emergency lighting so that during a power outage, means of egress and critical care areas will remain illuminated. This condition could affect all staff, patients and visitors resulting in failure of illumination under emergency conditions.

The finding is:

A. On 06/13/16 at 1:00pm while accompanied by the D.F. and H.M., document review determined that a written log of the 30 day testing for battery powered emergency lighting was not provided. There is no written documentation of testing for the 12 month period of 2015/2016. This condition does not comply with 18.2.9.1 and 7.9.3.

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on document review, the facility failed to maintain the emergency generator so that during a power outage the generator will operate as necessary. This condition could affect all staff, patients and visitors resulting in failure of the generator under emergency conditions going unnoticed by staff.

The finding is:

A. On 06/13/16 at 12:30pm while accompanied by the D.F. and H.M., document review determined that a written log of weekly visual inspections was not provided for the 12 month period of 2015/2016 in order to comply with NFPA 110, 6-4.2.