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Emergency illumination shall be provided for not less than 1½ hours in the event of failure of normal lighting. 7.9.2.1

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

Records review determined monthly testing of the emergency battery-powered emergency lighting system throughout the hospital was not documented.

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.

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 hospital.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1

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. 9.6.1.3

The facility failed to test the fire alarm system as required.

The annual inspection and testing of the fire alarm system in the nursing home was done by an outside company on 06/09/2016, exceeding one year from this survey.

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

This deficiency affected one (1) of one (1) fire alarm system. The fire alarm system serves the entire facility.

Smoke detectors must not be located in a direct airflow nor closer than 3 ft. (1 m) 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.

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined smoke detectors throughout the hospital and clinic were installed within 3 ft. of an air supply diffuser or air return vent.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected numerous smoke detectors in the facility. The smoke detection system serves the entire facility.

Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system. Sprinklers in high-temperature zones shall be of the high-temperature classification. 19.3.5.1, 9.7.1.1(1), NFPA 13 8.3.2, 8.3.2.5(1), Table 8.3.2.5(a)(2).

The facility failed to install the automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide adequate coverage for all portions of the building.

Observation determined:
1) One (1) sprinkler in the walk-in freezer located in the Kitchen was of ordinary-temperature classification. The walk-in freezer was equipped with an automatic defrosting feature. NFPA 13 requires sprinklers to be intermediate-rated sprinklers in automatic defrosting walk-in freezers and walk-in coolers.

2) Concealed spaces that contain combustible construction are required to be protected by the automatic sprinkler system. The concealed spaces above the suspended ceilings in the exit corridor near Resident Room 114 of the existing building had exposed wood framing and the area was not protected by the automatic sprinkler system.

3) Six (6) sprinklers in the Ambulance Garage, one (1) sprinkler in the Electrical Room 83, one (1) sprinkler in the Kitchen, one (1) sprinkler in the Maintenance Shop, one (1) sprinkler in the Sprinkler Riser Room, and one (1) sprinkler in the Clinic Storage Room installed within 7 ft. of horizontal discharge unit heaters were not high-temperature-rated. NFPA 13 requires high-temperature-rated sprinklers within a 7 ft. radius cylinder extending 7 ft. above and 2 ft. below horizontal discharge unit heaters.

4) Two (2) sprinklers in the Ambulance Garage installed between 7 ft. and 20 ft. on the discharge side of horizontal discharge unit heaters were not intermediate-temperature-rated. NFPA 13 requires intermediate-temperature-rated sprinklers within a 7 ft. to 20 ft. radius pie-shaped cylinder extending 7 ft. above and 2 ft. below horizontal discharge heaters; also a 7 ft. radius cylinder more than 7 ft. above horizontal discharge unit heaters.

Failure to install and maintain the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire.

The deficiency affected numerous sprinklers in the facility. The automatic sprinkler system serves the entire 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, 5.1.1.2

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

Inspections and tests include:
1) Inspect gauges of dry system weekly.
2) Inspect gauges of wet system monthly.
3) Inspect control valves monthly.
4) Inspect water alarm devices quarterly.
5) Inspect valve supervisory alarm devices quarterly.
6) Inspect supervisory signal devices quarterly.
7) Inspect hydraulic nameplate quarterly.
8) Test waterflow alarm devices quarterly.

Review of documentation determined the weekly and monthly inspections of the sprinkler system gauges, and monthly inspection of control valves were not completed.

This deficiency affected numerous inspections and tests of the automatic sprinkler system. The automatic sprinkler system serves the entire facility.

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

The facility failed to provide a documented risk assessment of building systems. NFPA 99, 4.2

Review of documentation and interview of staff determined the facility failed to conduct and document a risk assessment of building systems.

Failure to conduct a risk assessment of building systems increases the risk of injury or death due to fire.

This deficiency affected building systems throughout the entire facility.