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The facility failed to ensure exit access was readily accessible at all times.

Exits must terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge must be of required width and size to provide all occupants with safe access to a public way. 7.7.1

To ensure adequate exit capability, CMS requires asphalt or concrete surfaces from exterior exits to public ways.

Observation determined the northeast and east exterior exits traversed the lawn to get to a public way.

Failure to ensure exit access was readily available at all times increases the risk of death or injury due to fire.

The deficiency affected two (2) of eight (8) exits from the facility.

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 during all months 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.

The facility failed to test and maintain the wet chemical extinguishing system in the Kitchen in accordance with NFPA 17A, Standard for Wet Chemical Extinguishing Systems.

On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual.

At a minimum, this quick check or inspection shall include verification of the following:

1) The extinguishing system is in its proper location.
2) The manual actuators are unobstructed.
3) The tamper indicators and seals are intact.
4) The maintenance tag or certificate is in place.
5) No obvious physical damage or condition exists that might prevent operation.
6) The pressure gauge, if provided, shall be inspected physically or electronically to ensure it is in the operable range.
7) The nozzle blowoff caps, where provided, are intact and undamaged.
8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated.

If any deficiencies are found, appropriate corrective action shall be taken immediately. Where the corrective action involves maintenance, it shall be conducted by a trained service technician. Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions. At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semiannual maintenance inspections. 7.2.1 through 7.2.6

Review of documentation and interview with staff determined the monthly inspection of the wet chemical extinguishing system in the Kitchen had not been completed during February, and March 2024.

Failure to conduct monthly inspections of the wet chemical extinguishing system increases the risk of injury or death due to fire.

This deficiency affected one (1) of one (1) wet chemical extinguishing system in the facility.

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. 2010 NFPA 72, 14.1.1

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

Fire alarm system batteries shall be subjected to a load voltage test semiannually. NFPA 72, 14.4.2.2 item 5(e).

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. A load voltage test of the fire alarm system batteries was done during the annual inspection by an outside company on 12/21/2023. Records did not indicate any other load voltage test on the fire alarm system batteries in the past year.

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 two (2) required load voltage tests of the fire alarm batteries in the past year. The fire alarm system serves the entire facility.

Health care facilities shall be protected throughout by an approved, supervised automatic fire sprinkler system. 19.3.5.3, 19.3.5.4, 9.7.1.1(1)

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.

Sprinklers in high-temperature zones shall be high-temperature classification, and sprinklers in intermediate-temperature zones shall be intermediate-temperature classification. NFPA 13 8.3.2, 8.3.2.5(1), Table 8.3.2.5(a)(2)

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.

Observation determined one (1) sprinkler in the Loading Dock installed within 7 ft. of a horizontal discharge unit heater was not high-temperature-rated.

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

This deficiency affected one (1) of numerous areas 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, 4.1.4.1

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 and interview with staff determined the control valves and gauges of the automatic sprinkler system had not been inspected during all months in the past year.

2) Record review and interview with staff determined quarterly flow tests of the automatic sprinkler system were not completed as required. Records did not indicate a flow test was conducted during the second quarter in the past year.

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 ensure electrical wiring and electrical equipment met the requirements of NFPA 70, National Electrical Code.

Ground-fault circuit-interruption for personnel shall be provided as required. The ground-fault circuit-interrupter shall be installed in a readily accessible location. All 125-volt, single-phase, 15- and 20-ampere receptacles located in bathrooms, kitchens, rooftops, outdoors, indoor wet locations, locker rooms with associated showering facilities, garages and where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. 19.5.1.1, 9.1.2, NFPA 70, 210.8, 210.8(B)

Observation determined:

1) Two (2) electrical receptacles in the Kitchen were not ground-fault circuit-interrupter protected.

2) Two (2) electrical receptacles in PT Room 1 within 6 ft. of a sink were not ground-fault circuit-interrupter protected.

3) Two (2) electrical receptacles in Sleeping Room 1 within 6 ft. of a sink were not ground-fault circuit-interrupter protected.

Failure to provide electrical wiring and equipment in accordance with NFPA 70 increases the risk of injury or death due to fire.

The deficiency affected six (6) of numerous electrical receptacles in the facility.

The facility failed to ensure the emergency generator was in compliance with NFPA 99 and NFPA 110.

Record review and interview with staff determined:

1) The weekly inspection of the emergency generator was not conducted for all weeks during the past year.

2) The monthly load tests of the emergency generator during the past year exercised the emergency generator under load for 15 minutes not the required 30 minutes.

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.