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STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to arrange the exit access so that exits are readily accessible at all times in accordance with Life Safety Code 101 Section 19.2.2.2.4, 7.2.1.5.3. This deficient practice could affect all residents, staff and visitors within the facility if the Means of Egress is not maintained throughout the facility.

Maintenance shop door are equipped with locking/latching devices were two releasing operation were required to operate the door.

Life Safety Code 101 Section 7.2.1.5.3. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

The Director of Maintenance acknowledged the condition of the door during the time of the tour.

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:

No documentation was available during record review of the facility required testing of the battery-powered emergency lighting system at 30 day intervals for not less than 30 seconds or annually for not less than 1 ½ hours

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.

The Maintenance Director acknowledge the required testing of the emergency lighting during the tour of the facility.

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 area if code compliant exit signage is not provided for building egress.

Facility failed to provide proper exit signage in the Specialty Clinic directional arrows were pointing in the wrong direction.

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.

The Director of Maintenance acknowledge the lack of exit signage condition during the tour of the facility.

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.

Roll down fire door used as an opining protective for hazardous area requiring 1-hour separation between the main corridor and kitchen were not inspected annually.

NFPA 101 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.

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

STANDARD is not met as evidenced by: During the review of the facility records, with the staff, documentation was not available to confirm that the facility had a kitchen-hood-exhaust-system inspection as required by NFPA 96, (Chapter 11, Section 11.2.1). This deficient practice could affect all residents, and staff should a fire occur due to failure to operate effectively due to non-code compliant inspections and servicing. This was evidence by the following.

The facility was unable to provide further documentation indicating the inspection and servicing of the kitchen-suppression-system every six months.

11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months.

The Maintenance Director acknowledge the lack of inspections and servicing of the system.

STANDARD 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.

1. At the time of the survey, no documentation was available to indicate the Annual Testing of the fire alarm system had occurred in the past year.

2. Purchasing Material Management storage smoke detector broken loose from base taped in place.

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.

The Director of Maintenance acknowledge the lack of testing of the fire alarm system in the past year during the tour of the facility.

STANDARD 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.

1) Through record review, during the survey, it was determined that the facility failed to Quarterly inspect and test the automatic sprinkler system as required by NFPA 25.

2) Through record review, during the survey, it was determined that the facility failed to Quarterly inspect and test the automatic sprinkler system as required by NFPA 25 during all 4 quarter.

3) Pendent sprinkler heads located in the walk-in cooler and freeze observed to be older than 5 years old and shall be replaced.

NFPA 101 - 2012 Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are installed, inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

The Director of Maintenance acknowledge the lack of maintenance of the automatic sprinkler system deficiency during record review of the facility.

STANDARD 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.

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.

The Maintenance Director acknowledge the lack of maintenance and inspection requirements of the portable fire extinguishers deficiency during record review of the facility.

STANDARD 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 19.3.2.1 This deficient practice could affect all residents in all smoke compartment by allowing the spread of fire and smoke to the adjoining compartments.

Unsealed 2 ft. x 2 ft. penetrations in the fire rated walls in the Imagine corridor ot sealed to maintain the 1-hour fire resistance rating of the fire barrier, as required.

Life Safety Code Section 19.3.2.1 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 8-3.1.1 requires, in part, that the space between piping penetrations.

The Maintenance Director acknowledge the penetrations during a tour of the facility.

STANDARD not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to install electrical equipment in accordance with National Fire Protection Association 70, National Electrical Code. This deficient practice could affect all residents in the Pink corridor smoke compartments due to increased potential hazards of electrical fire.

The facility is utilizing an extension cord routed through wall as a substitute for fixed wiring to supply power to Housekeeping Office.

NFPA 70, National Electrical Code section 400-8 requires, in part, that flexible cords and cables not use as a substitute for the fixed wiring of a structure, and that they not be attached to a building surface.

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

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

The joints on the exhaust vents on both Type 2 clothes dryers in the laundry were connected by sheet metal screws.

NFPA 54, Section 10.4.4.2 Ducts for exhausting clothes dryers shall not be assembled with screws or other fastening means that extend into the duct and that would catch lint and reduce the efficiency of the exhaust system.

The dryer vent deficiencies were discussed with the Maintenance Director during the survey and again during the exit conference with the CEO.

This STANDARD not met as evidenced by: Through observation during the walkthrough of the survey it was determined that the facility failed to meet the Utilities- gas and electric requirements in accordance with NFPA 101 and NFPA 54.

Orifice for dryer not sized correctly currently set for 0-2000 feet according to dryer data plate.

NFPA 54, section 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft. (600 m) shall be reduced in accordance with one of the following methods:

(1) At the rate of 4 percent for each 1000 ft. (300 m) above sea level before selecting appropriately sized appliance
(2) As permitted by the authority having jurisdiction
(3) In accordance with the manufacturer's installation instructions

The deficient items were discussed with the Facilities staff and CEO and the Facilities Staff during the exit conference.

STANDARD 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 residents when staff are not trained in the emergency actions required during unusual condition that can occur in an actual emergency.

Fire drills are required to be conducted on each shift quarterly, the facility failed to conduct a fire during a twelve-month period.

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.

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

STANDARD not met as evidenced by: Based on observation and staff interview it was determined that the facility failed to maintain fire safe environment within the facility. This deficient practice could affect all patients, staff and visitors should a fire occur by the non-rated space heaters. This was evidence by the following.

Non- documented portable baseboard space heater used for heat found in the following locations, Human Recourse's, Same Day Surgery, Lab and Surgery coordinator's offices.

Life Safety Code, Section 19.7.8. Portable space-heating devices shall be prohibited in all heath care occupancies. Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee's areas where the heating elements of such devices do not exceed 212? F (100? C).

The CEO and Maintenance Director acknowledge the deficiency of the prohibited space heaters during the facility tour.

STANDARD 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 on the sixth floor smoke compartments due to increased potential hazards of electrical fire.

During the walk-through of the facility, the receptacle in the Conference room have been painted over and into energized electrical connections.

NFPA 70, National Electrical Code Article 370-25. Electrical outlets shall not be painted; potentially damaging electrical equipment causes an improper electrical connection between the plugged-in electrical appliance and the electrical source.

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

STANDARD is not met as evidenced by: Based on record review and documentation of inspection and testing of the non-hospital grade electrical outlets in patient care areas as required by sections 6.3.4.1.3 and 6.3.4.2.1.1 of NFPA 99, Health Care Facilities Code. This deficient practice could affect all residents, staff and visitors throughout the facility if the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade were to fail due to lack of testing. This was evidenced by the following:

No written test records of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patients care areas was conducted annually.

NFPA Standard: NFPA 99 Health Care Facilities Code (2012)
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).
6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or
general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.
6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.

The non-hospital grade electrical outlets testing at patient's care areas deficiency was discussed with the Director of Maintenance during the survey and again during the exit conference with the CEO.

STANDARD not met, Based on record review and staff interview during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8 This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss.

1) The facility failed to provide documentation at the time of the survey to reflect that the emergency generator was inspected weekly had occurred between August 2022 through August 2023.

2) The facility failed to provide documentation at the time of the survey to reflect that the emergency generator was exercised under load at 30 % least monthly for 30 minutes had occurred between August 2022 through August 2023.

3) Diesel annual fuel quality test not conducted as annually using applicable ASTM Standards.

4) At the time of the survey no records were available to verify testing and recording of battery
conductance testing in connection with the emergency power supply system (Emergency Generator) monthly.

NFPA 110-8.4 Operational Inspection and Testing.
8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

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