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Based on observation and interview, the facility failed to ensure that means of egress signage was properly displayed according to National Fire Protection Agency (NFPA) standards. This deficient practice affected one (1) of ten (10) smoke compartments, staff, patients, and other occupants of the building. The facility has the capacity for 42 beds.

The findings include:

Observation and interview on 04/03/14 at 10:30 AM with the Director of Maintenance (DOM) revealed a set of double doors at the back of the Emergency Department entrance that could not be used for exiting purposes. There was no signage that the doors were not exit doors and there were two illuminated exit signs attached to the corridor ceiling in close proximity to the doors. Doors that can be mistaken for exits must have signage stating the doors are not exits. The DOM agreed that signage should be added to the doors that it was not an exit and one of the exit signs should be removed from the ceiling.

The findings were revealed to the Administrator upon exit.

Reference: NFPA 101 (2000 Edition).

7.10.8.1* No Exit.
Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

Based on observation and interview, the facility failed to ensure smoke barrier doors were installed according to National Fire Protection Agency (NFPA) standards. This deficient practice affected one (1) of ten (10) smoke compartments, staff, patients, and other occupants of the building. The facility has the capacity for 42 beds.

The findings include:

Observation and interview on 04/03/14 at 10:20 AM with the Director of Maintenance (DOM) revealed a gap between the double doors at the "Pre Op" entrance on the first floor of the facility. These smoke barrier doors are required to have a suitable means to close the gap between the doors to help prevent smoke/fire from reaching other parts of the building in a fire situation. Interview with the DOM revealed he was aware the doors were part of a smoke barrier but was unaware there could be no gap between the doors.

The findings were revealed to the Administrator upon exit.

Based on observation and interview, the facility failed to ensure doors to hazardous areas were equipped with door closing devices as required by National Fire Protection Association (NFPA) standards. This condition affected three (3) of ten (10) smoke compartments, staff, patients, and other occupants of the building. The facility has the capacity for 42 beds.

The findings include:

Review of a Statement of Deficiencies issued to the facility after a survey on 04/22/10 revealed the facility received a deficiency for not having door-closing devices. The plan of correction received on 05/28/10 stated the facility would perform walk-through inspections to ensure doors to hazardous areas were maintained. In addition, the facility's plan of correction stated a door-closing device would be installed to the third floor mechanical room door.

Observation and interview on 04/03/14, at 10:30 AM, with the Director of Maintenance (DOM), revealed a first floor corridor door to a Mechanical Room did not have a door-closing device as required for a hazardous area. Interview with the DOM revealed he had not identified that the door did not have a door-closing device and agreed that a door-closing device was needed.

Observation and interview on 04/03/14, at 11:30 AM, with the DOM, revealed double doors to a mechanical room on the third floor corridor were not equipped with door closures. The mechanical room was observed to contain combustible storage. The DOM stated the room had been emptied of combustible storage because the facility was cited for not having door closures during the last survey on 04/22/10. The DOM stated combustible storage must have accumulated since the last survey. The plan of correction received on 05/28/10 from the facility stated the facility would be installing door-closing devices on these doors.

Observation and interview on 04/03/14, at 11:50 AM with the DOM revealed the second floor mechanical room doors also did not have door-closing devices. The DOM stated this room also had been emptied of combustible supplies after the 04/22/10 survey and that combustible supplies had been reintroduced into the area since the last survey.

The findings were revealed to the Administrator upon exit.

Based on observation and interview, the facility failed to ensure that egress ways were maintained according to National Fire Protection Agency (NFPA) standards. This deficient practice affected two (2) of ten (10) smoke compartments, staff, patients, and other occupants of the building. The facility has the capacity for 42 beds.

The findings include:

Observation and interview on 04/03/14 at 11:35 AM with the Director of Maintenance (DOM) revealed a door to the patient shower room on the third floor was observed to open and project more than seven inches into the corridor in the fully opened position. This condition could impede egress in an emergency and requires a door-closing device to remedy the situation. The DOM stated he was aware the door needed a door-closing device but had not installed one on the door.

Observation and interview on 04/03/14 at 11:45 AM revealed a door to the patient shower room on the second floor was observed to open and project more than seven inches into the corridor in the fully opened position. The DOM stated he was aware this door also needed a door-closing device but had not put one on the door.

The findings were revealed to the Administrator upon exit.

Reference: NFPA 101 (2000 Edition).

7.2.1.4.4*
During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open. Doors shall not open directly onto a stair without a landing. The landing shall have a width not less than the width of the door. (See 7.2.1.3.)

Exception: In existing buildings, a door providing access to a stair shall not be required to maintain any minimum unobstructed width during its swing, provided that it meets the requirement that limits projection to not more than 7 in. (17.8 cm) into the required width of a stair or landing when the door is fully open.

Based on an interview the facility failed to ensure battery-operated lighting was maintained according to National Fire Protection Association (NFPA) standards. This condition affected six (6) of six (6) smoke compartments, staff, patients, and other occupants of the building.
The findings include:

An interview on 04/03/14 at 10:40 AM with the Director of Maintenance (DOM) revealed he was unaware that emergency battery-operated lighting located in the generator room should be tested and logged. This type of lighting provides lighting to maintenance personnel at generator set and transfer switch locations in case the generator fails to start during a power failure.

In addition, the facility was provided with the testing requirements for emergency battery-operated lighting in the deficiency statement they received from the 04/22/10 survey.

The findings were revealed to the Administrator upon exit.

Reference: NFPA 110 (1999 Edition).

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-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.

Reference: NFPA 101 (2000 Edition).

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 11/2 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.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than

Based on interview the facility failed to ensure battery-operated lighting was maintained according to National Fire Protection Association (NFPA) standards. This condition affected six (6) of six (6) smoke compartments, staff, patients, and other occupants of the building.
The findings include:

Review of a Statement of Deficienices issued to the facility as a result of a survey on 04/22/10 revealed the facilty was cited for not having battery-operated lighting at generator set locations; however, at that time transfer switch locations were not required to have the battery-operated lighting units.

Observation and interview on 04/03/14 at 10:40 AM with the Director of Maintenance (DOM) revealed there was no battery-operated lighting at the generator transfer switches located in the boiler and chiller rooms as required. The DOM stated he was not aware these areas required battery-operated lighting. Emergency battery-operated lighting provides lighting to maintenance personnel at generator set and transfer switch locations in case the generator fails to start during a power failure.

Further interview with the DOM revealed the battery-operated lighting at the generator set was not being tested and logged.

The findings were revealed to the Administrator upon exit.
Reference: NFPA 110 (1999 Edition).

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-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.

Reference: NFPA 101 (2000 Edition).

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 11/2 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.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals

Based on record review, the facility failed to maintain the Waste Anesthetic Gas Disposal system (WAGD). This deficient practice affected staff, patients, and other occupants of the building. The facility has the capacity for 42 beds.

The findings include:

Review of the WAGD report dated 05/31/13 revealed the system had leaks. These systems must be properly maintained to perform as intended for patient care. The facility indicated the system was repaired but no documentation of repairs was provided at the time of exit on 04/03/14.

The findings were revealed to the Administrator upon exit.

Reference: NFPA 99 (1999 Edition).

4-3.5.9.1 Maintenance
The facility shall establish routine preventative maintenance programs applicable to the WAGD system.

4-3.5.9.2 Performance Tests
The facility shall establish routine testing programs to assure that the WAGD system performs as required in 4-3.4.3.

Based on interview and record review, the facility failed to ensure the emergency generator was maintained according to National Fire Protection Association (NFPA) standards. This condition affected six (6) of six (6) smoke compartments, staff, residents, and other occupants of the building.

The findings include:

Review of a Statement of Deficiencies issued to the facility after a survey on 04/22/10, revealed a deficiency was issued for failure to ensure the emergency generator was maintained according to NFPA standards. The facility's plan of correction received on 05/28/10 revealed the facility would create a policy to follow to ensure the deficiency was corrected. However, a record review and interview on 04/03/14, at 12:55 PM, with the Director of Maintenance (DOM) revealed a written weekly maintenance record on the emergency generator was not being kept. The DOM stated he was aware he should be keeping a written maintenance schedule but failed to do so. Proper maintenance and testing helps ensure the generator will operate as intended.

Reference: NFPA 110 (1999 Edition).

6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer ' s recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Based on interview and record review, the facility failed to ensure the emergency generator was maintained according to National Fire Protection Association (NFPA) standards. This condition affected ten (10) of ten (10) smoke compartments, staff, patients, and other occupants of the building. The facility has the capacity for 42 beds.

The findings include:

A review of the facility's Statement of Deficiencies (SOD) revealed the facility was cited on 04/22/10 for not keeping a written weekly maintenance schedule and for not operating the emergency generator transfer switch manually on a monthly basis as required. The facility's plan of correction received on 05/28/10 revealed the facility would create a policy to follow to ensure the deficiency was corrected.

A record review and interview on 04/03/14, at 12:55 PM, revealed the Director of Maintenance (DOM) was not keeping a written weekly maintenance record on the generator or manually operating the generator transfer switch on a monthly basis as required. The DOM stated he was aware he should be keeping a written maintenance schedule but failed to do so. The DOM stated the generator transfer switch transferred automatically and he was not aware he should be operating the transfer switch manually on a monthly basis. Proper maintenance and testing helps ensure the generator will operate as intended.

Reference: NFPA 110 (1999 Edition).

6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer ' s recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
6-4.5
Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-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.

Based on observation and interview, the facility failed to ensure that means of egress signage was properly displayed according to National Fire Protection Agency (NFPA) standards. This deficient practice affected one (1) of ten (10) smoke compartments, staff, patients, and other occupants of the building. The facility has the capacity for 42 beds.

The findings include:

Observation and interview on 04/03/14 at 10:30 AM with the Director of Maintenance (DOM) revealed a set of double doors at the back of the Emergency Department entrance that could not be used for exiting purposes. There was no signage that the doors were not exit doors and there were two illuminated exit signs attached to the corridor ceiling in close proximity to the doors. Doors that can be mistaken for exits must have signage stating the doors are not exits. The DOM agreed that signage should be added to the doors that it was not an exit and one of the exit signs should be removed from the ceiling.

The findings were revealed to the Administrator upon exit.

Reference: NFPA 101 (2000 Edition).

7.10.8.1* No Exit.
Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

Based on observation and interview, the facility failed to ensure smoke barrier doors were installed according to National Fire Protection Agency (NFPA) standards. This deficient practice affected one (1) of ten (10) smoke compartments, staff, patients, and other occupants of the building. The facility has the capacity for 42 beds.

The findings include:

Observation and interview on 04/03/14 at 10:20 AM with the Director of Maintenance (DOM) revealed a gap between the double doors at the "Pre Op" entrance on the first floor of the facility. These smoke barrier doors are required to have a suitable means to close the gap between the doors to help prevent smoke/fire from reaching other parts of the building in a fire situation. Interview with the DOM revealed he was aware the doors were part of a smoke barrier but was unaware there could be no gap between the doors.

The findings were revealed to the Administrator upon exit.

Based on observation and interview, the facility failed to ensure doors to hazardous areas were equipped with door closing devices as required by National Fire Protection Association (NFPA) standards. This condition affected three (3) of ten (10) smoke compartments, staff, patients, and other occupants of the building. The facility has the capacity for 42 beds.

The findings include:

Review of a Statement of Deficiencies issued to the facility after a survey on 04/22/10 revealed the facility received a deficiency for not having door-closing devices. The plan of correction received on 05/28/10 stated the facility would perform walk-through inspections to ensure doors to hazardous areas were maintained. In addition, the facility's plan of correction stated a door-closing device would be installed to the third floor mechanical room door.

Observation and interview on 04/03/14, at 10:30 AM, with the Director of Maintenance (DOM), revealed a first floor corridor door to a Mechanical Room did not have a door-closing device as required for a hazardous area. Interview with the DOM revealed he had not identified that the door did not have a door-closing device and agreed that a door-closing device was needed.

Observation and interview on 04/03/14, at 11:30 AM, with the DOM, revealed double doors to a mechanical room on the third floor corridor were not equipped with door closures. The mechanical room was observed to contain combustible storage. The DOM stated the room had been emptied of combustible storage because the facility was cited for not having door closures during the last survey on 04/22/10. The DOM stated combustible storage must have accumulated since the last survey. The plan of correction received on 05/28/10 from the facility stated the facility would be installing door-closing devices on these doors.

Observation and interview on 04/03/14, at 11:50 AM with the DOM revealed the second floor mechanical room doors also did not have door-closing devices. The DOM stated this room also had been emptied of combustible supplies after the 04/22/10 survey and that combustible supplies had been reintroduced into the area since the last survey.

The findings were revealed to the Administrator upon exit.

Based on observation and interview, the facility failed to ensure that egress ways were maintained according to National Fire Protection Agency (NFPA) standards. This deficient practice affected two (2) of ten (10) smoke compartments, staff, patients, and other occupants of the building. The facility has the capacity for 42 beds.

The findings include:

Observation and interview on 04/03/14 at 11:35 AM with the Director of Maintenance (DOM) revealed a door to the patient shower room on the third floor was observed to open and project more than seven inches into the corridor in the fully opened position. This condition could impede egress in an emergency and requires a door-closing device to remedy the situation. The DOM stated he was aware the door needed a door-closing device but had not installed one on the door.

Observation and interview on 04/03/14 at 11:45 AM revealed a door to the patient shower room on the second floor was observed to open and project more than seven inches into the corridor in the fully opened position. The DOM stated he was aware this door also needed a door-closing device but had not put one on the door.

The findings were revealed to the Administrator upon exit.

Reference: NFPA 101 (2000 Edition).

7.2.1.4.4*
During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open. Doors shall not open directly onto a stair without a landing. The landing shall have a width not less than the width of the door. (See 7.2.1.3.)

Exception: In existing buildings, a door providing access to a stair shall not be required to maintain any minimum unobstructed width during its swing, provided that it meets the requirement that limits projection to not more than 7 in. (17.8 cm) into the required width of a stair or landing when the door is fully open.

Based on an interview the facility failed to ensure battery-operated lighting was maintained according to National Fire Protection Association (NFPA) standards. This condition affected six (6) of six (6) smoke compartments, staff, patients, and other occupants of the building.
The findings include:

An interview on 04/03/14 at 10:40 AM with the Director of Maintenance (DOM) revealed he was unaware that emergency battery-operated lighting located in the generator room should be tested and logged. This type of lighting provides lighting to maintenance personnel at generator set and transfer switch locations in case the generator fails to start during a power failure.

In addition, the facility was provided with the testing requirements for emergency battery-operated lighting in the deficiency statement they received from the 04/22/10 survey.

The findings were revealed to the Administrator upon exit.

Reference: NFPA 110 (1999 Edition).

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-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.

Reference: NFPA 101 (2000 Edition).

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 11/2 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.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than

Based on interview the facility failed to ensure battery-operated lighting was maintained according to National Fire Protection Association (NFPA) standards. This condition affected six (6) of six (6) smoke compartments, staff, patients, and other occupants of the building.
The findings include:

Review of a Statement of Deficienices issued to the facility as a result of a survey on 04/22/10 revealed the facilty was cited for not having battery-operated lighting at generator set locations; however, at that time transfer switch locations were not required to have the battery-operated lighting units.

Observation and interview on 04/03/14 at 10:40 AM with the Director of Maintenance (DOM) revealed there was no battery-operated lighting at the generator transfer switches located in the boiler and chiller rooms as required. The DOM stated he was not aware these areas required battery-operated lighting. Emergency battery-operated lighting provides lighting to maintenance personnel at generator set and transfer switch locations in case the generator fails to start during a power failure.

Further interview with the DOM revealed the battery-operated lighting at the generator set was not being tested and logged.

The findings were revealed to the Administrator upon exit.
Reference: NFPA 110 (1999 Edition).

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-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.

Reference: NFPA 101 (2000 Edition).

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 11/2 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.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals

Based on record review, the facility failed to maintain the Waste Anesthetic Gas Disposal system (WAGD). This deficient practice affected staff, patients, and other occupants of the building. The facility has the capacity for 42 beds.

The findings include:

Review of the WAGD report dated 05/31/13 revealed the system had leaks. These systems must be properly maintained to perform as intended for patient care. The facility indicated the system was repaired but no documentation of repairs was provided at the time of exit on 04/03/14.

The findings were revealed to the Administrator upon exit.

Reference: NFPA 99 (1999 Edition).

4-3.5.9.1 Maintenance
The facility shall establish routine preventative maintenance programs applicable to the WAGD system.

4-3.5.9.2 Performance Tests
The facility shall establish routine testing programs to assure that the WAGD system performs as required in 4-3.4.3.

Based on interview and record review, the facility failed to ensure the emergency generator was maintained according to National Fire Protection Association (NFPA) standards. This condition affected six (6) of six (6) smoke compartments, staff, residents, and other occupants of the building.

The findings include:

Review of a Statement of Deficiencies issued to the facility after a survey on 04/22/10, revealed a deficiency was issued for failure to ensure the emergency generator was maintained according to NFPA standards. The facility's plan of correction received on 05/28/10 revealed the facility would create a policy to follow to ensure the deficiency was corrected. However, a record review and interview on 04/03/14, at 12:55 PM, with the Director of Maintenance (DOM) revealed a written weekly maintenance record on the emergency generator was not being kept. The DOM stated he was aware he should be keeping a written maintenance schedule but failed to do so. Proper maintenance and testing helps ensure the generator will operate as intended.

Reference: NFPA 110 (1999 Edition).

6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer ' s recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Based on interview and record review, the facility failed to ensure the emergency generator was maintained according to National Fire Protection Association (NFPA) standards. This condition affected ten (10) of ten (10) smoke compartments, staff, patients, and other occupants of the building. The facility has the capacity for 42 beds.

The findings include:

A review of the facility's Statement of Deficiencies (SOD) revealed the facility was cited on 04/22/10 for not keeping a written weekly maintenance schedule and for not operating the emergency generator transfer switch manually on a monthly basis as required. The facility's plan of correction received on 05/28/10 revealed the facility would create a policy to follow to ensure the deficiency was corrected.

A record review and interview on 04/03/14, at 12:55 PM, revealed the Director of Maintenance (DOM) was not keeping a written weekly maintenance record on the generator or manually operating the generator transfer switch on a monthly basis as required. The DOM stated he was aware he should be keeping a written maintenance schedule but failed to do so. The DOM stated the generator transfer switch transferred automatically and he was not aware he should be operating the transfer switch manually on a monthly basis. Proper maintenance and testing helps ensure the generator will operate as intended.

Reference: NFPA 110 (1999 Edition).

6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer ' s recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
6-4.5
Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-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.