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Based on observation and staff interview the facility failed to provide the level of lighting as required by the Life Safety Code, (NFPA 101) 2012 edition section 7.8.1.4. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 03/19/2024 between 12:00pm and 4:00pm, it was revealed by observation that the exterior lights for A2 Exit (by room 158) of the exit discharges had only one bulb for illumination. Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area.

An interview with the Maintenance Director verified these deficient findings at the time of discovery.

The building is divide Based on observation and staff interview, the facility failed to maintain and/or install proper exit signage under NFPA 101 (2012 edition), Life Safety Code sections 19.2.10.1, 7.10.1.2.2, 7.10.8.3, 7.10.8.31 and 7.10.8.3.2. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 03/19/2024 between 12:00pm and 4:00pm, it was revealed by observation that the door leading to the Courtyard from the South corridor was missing a "NO EXIT" sign. The NO EXIT sign shall have the word NO in letters 2 in. (51 mm) high, with a stroke width of 3.8 in. (9.5 mm), and the word EXIT in letters 1 in. (25 mm) high, with the word EXIT below the

An interview with the Maintenance Director verified these deficient findings at the time of discovery.

Based on observation, a review of available documentation, and staff interview, the facility failed to inspect and maintain the fire sprinkler system per NFPA 101 (2012 edition), Life Safety Code, section 9.7.5, and NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, sections 5.1.1.2, and 5.3.2.1. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 03/19/2024 between 12:00pm 4:00pm, it was revealed by a review of available documentation the facility failed to provide documentation that the five (5) year sprinkler system testing was performed.

An interview with the Maintenance Director verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain spacing between storage and the sprinkler system per NFPA 101 (2012 edition), Life Safety Code, Section 9.7.5, NFPA 25 (2011 edition), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 5.2.1.2, and NFPA 13 (2010 edition), Standard for the Installation of Sprinkler Systems, Sections 8.6.5.3.2 and 8.15.9. These deficient findings could a patterned impact on the residents within the facility.

Findings include:

On 03/19/2024 between 12:00pm 4:00pm, it was revealed by observation that storage materials had been placed on a storage cabinet, bringing the storage materials within the required 18 inch clearance area under the sprinkler heads. These obstructions were found in storage closit in room 511

An interview with the Maintenance Director verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to conduct fire drills under varied times and conditions per NFPA 101 (2012 edition), Life Safety Code, sections 19.7.1.6, 4.7.4, and 4.6.1.1. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 03/19/2024 between 12:00pm and 4:00pm, it was revealed by a review of available documentation that fire drills were not completed:

1) Third Shift missing Forth Quarter (October - December) drill completely.
2) First Shift missing Second Quarter (July - September) drill completely.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to inspect fire doors per NFPA 101 (2012 edition), Life Safety Code section 8.3.3.1, and NFPA 80 (2010 edition), Standard for Fire Doors and Other Opening Protectives, section 5.2.1. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 03/19/2024 between 12:00pm and 4:00pm, it was revealed by observation that the following fire doors and/or fire door frames had fire rating tags covered with paint and/or missing door rating tags.

1) Two (2) hour Fire doors leading to Administration - painted tags on door frame
2) Two (2) hour Fire doors off elevator lobby - painted tags on door frame

An interview with the Maintenance Director verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to install and maintain generators per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.3, 6.4.1.1.16.2 and 6.4.1.1.17, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, sections 8.4.9, 8.4.9.1, 8.4.9.2 and 8.4.9.5.1. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 03/19/2024, between 12:00pm and 4:00pm, it was revealed by a review of available documentation of the emergency generator maintenance and testing that the facility could not provide documentation that a 36 month four (4) hour load bank test had been performed.

An interview with the Maintenance Director verified these deficient findings at the time of discovery.

Based on a review of available documentation and staff interview, the facility failed to test and inspect the generator per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.4, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, section 8.4.1 and 8.4.2. These deficient findings could have a widespread impact on the residents within the facility.

Findings include:

On 03/19/2024, between 12:00pm and 4:00pm, it was revealed by a review of available documentation of the emergency generator maintenance and testing, that the facility could not provide documentation of an annual generator inspection at the time of survey.

An interview with the Maintenance Director verified these deficient findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain the usage of electrical adaptive devices per NFPA 99 (2012 edition), Health Care Facilities Code, sections 10.5.2.3.1 and 10.2.4.2.1, NFPA 70, (2011 edition), National Electrical Code, sections 400-8, and UL 1363. This deficient finding could have an isolated impact on the residents within the facility.

Findings include:

On 03/19/2024 between 12:00pm and 4:00pm, it was revealed by observation that there were several electrical appliances plugged into a power strip in the following areas:

1) Daisy chained appliances in the Ambulance Brake room
2) Daisy chained appliances in Office 502

An interview with the Maintenance Director verified these deficient findings at the time of discovery.