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Based on record review and staff interview the facility failed to ensure that battery powered emergency lighting is tested and installed correctly. This deficient practice could result in the lack of lighting during an interruption of power, affecting 33 patients in one of three smoke zones. The facility has a capacity of 36 with a census of 32.

Findings include:

During the survey on November 30, 2016 between the hours of 11:00 AM and 5:15 PM the following is observed:

1. The medication room is not equipped with emergency lighting. The light switch located in the medication room is switchable.

The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Computer-based, self-testing/self-diagnostic battery operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) The emergency lighting equipment shall automatically perform annually a test for a minimum of 11/2 hours.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.3(2) and (3).
(5) The computer-based system shall be capable of providing a report of the history of tests and failures at all times. 2012 NFPA 101, 7.9.3.1.3

Review of the following NFPA Standard revealed: The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention. 2012 NFPA 101, 7.9.2.7

Based on observation and staff interview the facility does not assure alcohol-base/alcohol-gel hand sanitizer containers are installed properly. This deficient practice would allow the alcohol-base hand sanitizer (ABHS) product to come into contact with ignition sources and result in a fire, affecting 33 patients in one of three smoke zones. The facility has a capacity of 36 with a census of 32.

Findings include:

During the survey on November 30, 2016 between the hours of 11:00 AM and 5:15 PM the following is observed:
1. The ABHS located in the R & F room is installed within one inch of the light switch.

The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met:

(1) Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 ft (1830 mm).

(2) The maximum individual dispenser fluid capacity shall be as follows:

(a) 0.32 gal (1.2 L) for dispensers in rooms, corridors, and areas open to corridors
(b) 0.53 gal (2.0 L) for dispensers in suites of rooms

(3) Where aerosol containers are used, the maximum capacity of the aerosol dispenser shall be 18 oz. (0.51 kg) and shall be limited to Level 1 aerosols as defined in NFPA30B, Code for the Manufacture and Storage of Aerosol Products.

(4) Dispensers shall be separated from each other by horizontal spacing of not less than 48 in. (1220 mm).

(5) Not more than an aggregate 10 gal (37.8 L) of alcohol-based hand-rub solution or 1135 oz (32.2 kg) of Level 1 aerosols, or a combination of liquids and Level 1 aerosols not to exceed, in total, the equivalent of 10 gal (37.8 L) or 1135 oz (32.2 kg), shall be in use outside of a storage cabinet in a single smoke compartment, except as otherwise provided in 19.3.2.6(6).

(6) One dispenser complying with 19.3.2.6 (2) or (3) per room and located in that room shall not be included in the aggregated quantity addressed in 19.3.2.6(5).

(7) Storage of quantities greater than 5 gal (18.9 L) in a single smoke compartment shall meet the requirements of NFPA 30, Flammable and Combustible Liquids Code.

(8) Dispensers shall not be installed in the following locations:

(a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source

(b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source

(c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source

(9) Dispensers installed directly over carpeted floors shall be permitted only in sprinklered smoke compartments.

(10) The alcohol-based hand-rub solution shall not exceed 95 percent alcohol content by volume.

(11) Operation of the dispenser shall comply with the following criteria:

(a) The dispenser shall not release its contents except when the dispenser is activated, either manually or automatically by touch-free activation.

(b) Any activation of the dispenser shall occuronly when an object is placed within 4 in. (100 mm) of the sensing device.

(c) An object placed within the activation zone and left in place shall not cause more than one activation.

(d) The dispenser shall not dispense more solution than the amount required for hand hygiene consistent with label instructions.

(e) The dispenser shall be designed, constructed, and operated in a manner that ensures that accidental or malicious activation of the dispensing device is minimized.

(f) The dispenser shall be tested in accordance with the manufacturer ' s care and use instructions each time a new refill is installed.

2012 NFPA 101, 19.3.2.6*

Based on observation, interview and record review, the facility failed to provide and maintain documentation of annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting all patients in all three smoke zones. The facility has a capacity of 36 with a census of 32.

Findings include:

During the survey on November 30, 2016 between the hours of 11:00 AM and 5:15 PM the following is observed:

1. During the record review it was revealed that the annual fire alarm inspection testing was 5 days overdue. The most recent annual was performed on 3-19-16 and the previous year was performed on 3-14-15.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101, 9.6.1.3

Based on record review and staff interview the facility failed to provide a written fire safety plan that addresses the evacuation of each smoke compartment. The deficient practice may prevent the staff in identifying the need to evacuate occupants beyond the compartment of origin to another smoke compartment, affecting all patients in all three smoke zones. The facility has a capacity of 36 with a census of 32.

Findings include:

During the survey on November 30, 2016 between the hours of 11:00 AM and 5:15 PM the following is observed:

1. Review of the fire evacuation procedures revealed that no plans for individual smoke compartments are available, only a whole building evacuation plan.


The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. Employees of health care occupancies shall be instructed in life safety procedures and devices. 2012 NFPA 101, 19.7.1.1-3,8

Review of the following NFPA Standard revealed: For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel.
The basic response required of staff shall include
the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy's fire safety plan
Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
2012 NFPA 101, 19.7.2.1-2

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all patients in all three smoke zones. The facility has a capacity of 36 with a census of 32.

Findings include:

During the survey on November 30, 2016 between the hours of 11:00 AM and 5:15 PM the following is observed:

1. The fire drills performed before July 2016 do not have any scenarios documented. The fire drills performed after July 2016 do not have enough detailed information documented.

The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 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. When drills are conducted between 9:00 p.m. and
6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Employees of health care occupancies shall be instructed in life safety procedures and devices. 2012 NFPA 101, 19.7.1.1-8

Review of the following NFPA Standard revealed: The basic response required of staff shall include the following:

(1) Removal of all occupants directly involved with the fire Emergency

(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff

(3) Confinement of the effects of the fire by closing doors to isolate the fire area

(4) Relocation of patients as detailed in the health care occupancy ' s fire safety plan

2012 NFPA 101, 19.7.2.1.2