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Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with NFPA 101, Life Safety Code Sections 21.2.9 and 7.9.3.1.1.

This was evidenced by the following:
1. No records or inadequate documentation for emergency lighting 30 second monthly and 90-minute annual testing.
2. Missing required emergency lighting at the generator transfer switch.

NFPA 101, 7.9.3.1.1 Periodic Testing of Emergency Lighting Equipment. (1) A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. (3) 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.

NFPA 101, 7.9.2.3. The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting.

This deficient practice could affect occupants and staff if emergency lighting is needed during a power loss.

This was discussed during the exit conference.

Based on observation and record review it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, Chapter 11, 11.7.1

This was evidence by the following:
1. No records or documentation for kitchen hood suppression system annual inspection and servicing.

NFPA 96, 11.7.1 Inspection and servicing of the cooking equipment shall be made at least annually by properly trained and qualified persons.

This deficient practice could affect all residents, and staff should a fire occur and the suppression system fails to operate effectively due to non-code compliant inspections and servicing.

This deficiency was discussed during the exit conference.

Based record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the NFPA 101, Life Safety Code Section 21.3.4, 9.6.1.5, and NFPA 72.

This was evidenced by:
1. No records or documentation for 2-year smoke detector sensitivity testing.

NFPA 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.

NFPA 72, 14.2.1.1.2 Inspection, testing, and maintenance programs shall verify correct operation of the system.

NFPA 72, 14.4.5.3* In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7.

NFPA 72, 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.

NFPA 72, 14.4.5.3.2 Sensitivity shall be checked every alternate year.

This deficiency was discussed during the exit conference.

Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25,5.3.2.1.

This was evidence by the following.
1. Fire sprinkler riser gauges in PT dry valve room appear to exceed their service life of 5yrs.

NFPA 101 Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.12, and NFPA 25, 5.2.1

NFPA 25, 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge.

This deficient practices could affect all residents, staff and visitors should the automatic standpipe system fail to operate in a timely and effective manner due to non-code compliant maintenance.

This deficiency was discussed during the exit conference.

Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3

This was evidenced by the following:
1. Fire doors near room 11 are missing latching hardware on both doors.
2. Fire rated doors near lab do not latch.

NFPA 101, 19.3.6.3.1 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke.

NFPA 101, 19.3.6.3.2, (2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors and gaps in the door smoke seal.

This was discussed during exit conference.

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Sections 19.7.1.6 and 4.7.4.

This was evidenced by the following:
1. Fire drills were not conducted during varying times and conditions. Time of drills were too close to previous drills on 2nd & 3rd shifts.

NFPA 101 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

NFPA 101, 4.7.4. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

This was discussed during the exit conference.

Based on observation, it was determined that the facility failed to maintain proper electrical practices in accordance with NFPA 101, 9.1.2, and NFPA 70, National Electrical Code Section 110.12.

This was evidenced by the following deficiencies:

1. Open electrical junction boxes and exposed wiring in Endoscopy mechanical closet.

NFPA 101, Section 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code

NFPA 70, Section 110.12 Electrical equipment shall be installed in a neat and skillful manner.

This deficient practice could affect all occupants and staff throughout the smoke compartment if improper maintenance of electrical equipment causes a fire.

The deficiency was discussed during the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110.

This was evidence by the following:
1. No records or documentation of generator battery monthly conductance testing.
2. No records for generator annual fuel sample.
3. No records for annual generator load testing.

NFPA 110, 8.3.7.1 The required monthly testing and recording of electrolyte specific gravity or conductance results (Reserve Capacity, "RC") of the lead acid batteries in connection with the emergency power supply system (generator) were not completed as required. The emergency power supply system provides power for emergency lighting.
Ref: 2012 NFPA 101 Section 21.2.9, 7.9.2.4, 4.6.12.1 / 2010 NFPA 110 Section 8.3.7.1

NFPA 110, 8.4.1 EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

NFPA 110, 8.3.1 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

This was discussed during the record review and again during the exit conference.