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Testing of required emergency lighting systems shall be permitted to be conducted as follows:

1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
3) Functional testing shall be conducted annually for a minimum of 1½ hours if the emergency lighting system is battery powered.
4) The emergency lighting equipment shall be fully operational for the duration of the tests.
5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.1

The facility failed to ensure the emergency lighting was in proper operating condition to provide 1½ hours of emergency illumination in the event of failure of normal lighting.

Record review determined:
1) The facility failed to conduct a 30-second monthly test of the emergency battery back-up lights in the past year.
2) The facility failed to conduct a 90-minute annual test of the emergency battery back-up lights in the past year.

Failure to test and maintain the emergency lights in accordance with NFPA 101 increases the risk of death or injury due to fire.

The deficiency affected all emergency battery back-up lights throughout the building.

Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 19.3.2.1

The facility failed to ensure hazardous areas in fully sprinklered existing health care occupancies were separated from other spaces by smoke-resisting partitions and latching doors.

Observation determined:

1) The east corridor door to Materials Management Storage Room had a bungee strap holding the door open that required a manual releasing action to close.

2) The north corridor door to Materials Management Storage Room had a bungee strap holding the door open that required a manual releasing action to close.

3) The west corridor door to the Laundry failed to self-close and latch.

Failure to ensure hazardous areas were separated from other spaces by smoke-resisting partitions increases the risk of death or injury due to fire.

The deficiency affected two (2) of numerous hazardous areas in the facility.

The facility failed to ensure smoke detectors were installed, maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm and Signaling Code.

1) In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1

Observation determined numerous smoke detectors throughout the facility were installed within 36 in. of an air supply diffuser or return air opening.

2) Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years. 19.3.4.5, 9.6.2.10.1.1, NFPA 72 14.4.5.3

Review of the fire alarm test results indicated the smoke detection system did not have sensitivity testing at frequencies in compliance with the minimum requirements of NFPA 72.

No records were available to indicate smoke detectors were sensitivity tested at the required two-year test interval.

Failure to install, maintain, inspect and test the smoke detection system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected all smoke detectors in the facility.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25, 4.1.4.1

All backflow preventers installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer. NFPA 25, 13.6.2.1

Fire department connections shall be inspected quarterly to verify the following:

(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate smoothly.
(3) Plugs or caps are in place and undamaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
(8) The fire department connection clapper(s) is in place and operating properly. NFPA 25, 13.7.1.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

1) Record review determined the annual back flow preventer test was conducted on 03/12/2021 and 09/06/2022. The time period exceeded 1 year.

2) Observation determined the fire department connection located on the south side of the building was not accessible due to snow drifts.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected the complete automatic sprinkler system, which serves the entire facility.

The facility failed to conduct fire drills as required.

Fire drill records review determined the fire drill conducted during February 2022 did not include the simulation of an emergency phone call to the fire department.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of twelve (12) required drills in the past year.

The facility failed to ensure the emergency generator was in compliance with NFPA 99, Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems.

Review of generator test records and interview with staff:

1) Indicated the monthly tests of the emergency generator were not documented in the past year.

2) Did not indicate the emergency generator was exercised under load for 4 continuous hours in the past 36 months.

Failure to inspect, test and maintain the emergency generator in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.