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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.

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 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: 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.

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 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: 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.

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 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: 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. This was evidence by the following.

Facility failed to provide proper exit signage at Fitness Center exit door.

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

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.

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 hazardous areas in accordance with Life Safety Section 19.3.2.1. This deficient practice could affect all residents and staff in the main smoke compartment including the beauty shop should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidence by the following.

The X-ray corridor doors are not arranged to be self-closing, Door closer arm was disconnected from the closing device.

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

Life Safety Code Section 19.3.2.1 requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting construction. Doors installed to protect hazardous areas must be self-closing or automatic closing.

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: 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 19.3.7.3 This deficient practice could affect all residents in all smoke compartment by allowing the spread of fire and smoke to the adjoining compartments. This was evidenced by the following:

Penetrations in the ceiling of the supply storage closet were not sealed to maintain the 30-minute fire resistance rating of the smoke barrier, as required.

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

Life Safety Code Section 19.3.7.3 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 8-3.6.1 requires, in part, that the space between piping penetrations.

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 first shift in the second and third quarter of 2019.

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 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 space heaters are being utilized in the Reception Area, Nurses Station, DON Office.

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

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).

STANDARD is 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 space heaters are being utilized in the X-Ray room, Material Management, Nurses Station, DON office and Scheduling Office.

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

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).

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to utilize Medical-Grade Power Strip in the vicinity of wet location of patient care as required by 2012 NFPA 99 Section 10.2.3.6, 10.2.4 and NFPA 70. This deficient practice could affect all residents and staff within the wet location patient care area due to increased potential electrical hazard. This was evidence by the following:

Non-rated Medical-Grade Power Strip suppling power to movable plug-connected components mounted to a rack, table and pedestal in both operating rooms are not compliant with UL 1363A specifications.

The Maintenance Director acknowledged the non-rated medical-grade power strips in the operating rooms during the tour of the facility.

NFPA 99 section 10.2.4.2 Adapters and extension cords meeting the requirements of 10.2.4.2.1 through 10.2.4.2.3 shall be permitted.