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Based on observation and interview with staff, the facility failed to maintain exit and directional signs that are displayed with continuous illumination, also served by the emergency lighting system in accordance with section 7.10. 18.2.10.1. Findings include:

The exit sign light above the exterior door, adjacent to Urgent Care Center, was burnt out.

Based on observation, interview with staff, and review of the Fire Alarm Records, the facility failed to test, and maintain the system in accordance with NFPA 70 National Electrical Code and NFPA 72. The facility failed to test the fire alarm system required for life safety program with an approved maintenance and testing program complying with applicable requirements of NFPA 72. 9.6.1.4 Findings include:

a) the annual test was not signed.
b) the removal of the yellow tag 2/25/2013 was not re-tested and documented with a re-acceptance test.
c) all devices; example Combination Fire and Smoke Dampers could not be depicted on the annual test. All devices connected to the fire alarm shall be tested annually.

Based on observation, interview with staff, the facility failed to maintain corridors free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10 Findings include:

Weight scales were found staged and set up in the egress corridor north of Administration.

Based on interview with staff, review of the Emergency Operations Plan Outline dated 1/24/2013 , the facility failed to develop a program for an effective disaster preparedness, mitigation, response, and recovery. The facility failed to provide contingency planning for disasters that included a minimum stockpiling or ensuring immediate or at least uninterrupted access to critical materials such as the following:
(a) Pharmaceuticals
(b) Medical supplies
(c) Food supplies
(d) Linen supplies
(e) Industrial and potable (drinking) waters. Findings included:

Staff members B and C was asked to provide documented details about emergency preparedness on Thursday November 21, 2012, at 3:30 pm. Staff indicated that they were in the process of identifying and procurement of needed rations to sustain the facility The document provided "Emergency Operation Plan" approved 1/24/13 was not implemented, the facility had not executed a drill, educated staff, provided for Patient Management (clinical needs), or planned for staff management in accordance with NFPA 99 1999 edition Chapter 11.

Based on observation, interview with staff, the facility failed to provide electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings include:

1)The facility had not conducted Impedance Ground Testing for Patient Care areas in the hospital. Grounding System Testing of the grounding system in Patient Care Areas as defined by NFPA 99 1999 edition chapter 2 Definitions shall be tested by voltage measurements and impedance measurements 3-3.3.2.1.
1. Testing shall be performed after initial installation, replace-, meant ,or servicing of the device.
2. Additional testing shall be performed at intervals defined by documented performance data.
3 Record keeping shall be kept and available for review.

2) Based on review of the Bio Medical Records and interview with staff, the facility failed to have records of Equipment Repairs and Testing that is up to date. A device Fukuda (screen) model 36320 was repaired 9/27/2013, however the records were not available for review. The Bio Medical Vendor had the copies of the repair and had not provided the facility with documentation by either electronic or paper record.