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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 19.2.1, 7.2.1.5.4. This deficient practice could affect all residents, staff and visitors within the facility if the Means of Egress is not maintained throughout the facility. This was evidenced by the following:

The Old Surgery egress doors were equipped with locking/latching and sliding devices were two releasing operation were required to operate the door.

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

Life Safety Code 101 Section 7.2.1.5.4. A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operated with not more than one releasing operation.

STANDARD is not met as evidenced by: Based on record 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 through-out the entire hospital.

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: During the review of the facility records, with staff, documentation was not available to confirm that the facility had a kitchen-hood-exhaust-system cleaning schedule as required by NFPA 96, (Chapter 8, Section 8-3), and observation of the kitchen gas fired cooking equipment did not meet the requirements of the 2012 Edition of NFPA 54 Fuel and Gas Code 9.6.1.2. These deficient practices could affect all residents, and staff should a fire occur. This was evidence by the following;

1.No written report was available to confirm that the facility had the kitchen-hood-exhaust-system cleaned as required by NFPA 96. NFPA 96, Chapter 8, Section 8-3.1 Hoods, grease removal devices, fans, ducts and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surface becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire system shall be inspected by a properly trained, qualified and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

2.Gas fired cooking equipment with casters where not limited by a restraining device. NFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of appliance with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufactures installation instructions.

The Maintenance Director acknowledge the violation noted with the kitchen cooking appliances.

STANDARD is not met as evidenced by: During the walk through of the facility, with the Maintenance Director the facility failed to maintain the fire alarm system per NFPA 72 and 2012 Life Safety Code 101. Failure to maintain 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:
1.The fire alarm systems located in the Outer Archive and X-ray file rooms has a trouble signal on the main panel that that do not indicate failures nor will the reset to normal status.
2. At the time of the survey, no documentation was available to indicate the Annual Testing of the fire alarm system located in the basement Data room had occurred since 2017 according to the Inspection tag.

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

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 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)One (1) painted sprinkler head in Basement Mechanical Room
2)Four (4) painted sprinkler head in Food Service Dish Room
3)Four (4) painted sprinkler head in Food Service Storage Room
4)Two (2) painted sprinkler head in Housekeeping Storage Room
5)Two (2) painted sprinkler head in GI south
6)Five (5) painted sprinkler head in Laundry Room
7)One fire sprinkler head is obstructed by the light fixtures in the Old Surgery scrub room.

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 suppression 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 suppression 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 suppression 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 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: It was determined by record review and staff interview during the course of the survey, the facility failed to perform and document the exercising of all fire and smoke damper at least every four years, in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems; section 3-4.7 Maintenance. This deficient practice could affect all residents, staff and visitors if the smoke dampers malfunction due to improper maintenance should a fire occur. This was evidenced by the following:

Records were not available at the time of the survey to document the inspection and testing operation of the fire dampers install in the facility as required every four years.

The smoke and fire dampers deficiency item was discussed with the Director of Maintenance during record review of required documentation.

NFPA 90A, Chapter 3, Section 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

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 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 on each shift quarterly, the facility failed to conduct a fire drill on the second shift in the third quarter.

The Director of Maintenance 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.

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 for 1-1/2-hour duration at the transfer switches. accordance with NFPA 99 - 6.6.3.1.1, Life Safety 101- 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 evidence of a required battery back-up emergency lighting at generator # 1 transfer switch.

The Maintenance Director acknowledge the lack of required battery back-up emergency lighting at the generator transfer switch during the tour of the facility.

2012 NFPA 99 Section 6.6.3.1.1 The life safety and critical branches shall have an alternate source of power separate and independent from the normal source that will be effective for a minimum of 11?2 hours after loss
of the normal source.

STANDARD is not met as evidenced by: 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. This was evidenced by the following.

1.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 in the past year.
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.Generator was not equipped with battery-powered lighting. 5-3.1 The Level I and Level 2 EPS equipment location shall be provided with batty-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

The emergency power supply system deficiency item was discussed with the Maintenance Director during the survey.

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.

NFPA 110-2010 section 5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is located outside the building.

NFPA 110-2010 section 7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting.