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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.

Review of records indicated the facility failed to conduct a 30-second test of the emergency battery back-up lights during May and September 2019.

Failure to provide emergency lighting as required increases the risk of death or injury due to fire.

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

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 one (1) sprinkler in the walk-in freezer and one (1) sprinkler in the walk-in cooler, located in the Kitchen were of ordinary-temperature classification. The walk-in freezer and cooler were 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.

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 two (2) of numerous sprinklers in the facility. The automatic sprinkler system serves the entire facility.

Buildings containing nursing homes shall be protected throughout by an approved, supervised, automatic sprinkler system in accordance with Section 9.7. 19.3.5.1

All automatic sprinkler systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 9.7.5

Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. NFPA 25, 5.3.2.1

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Record review determined the sprinkler system gauges were last replaced or calibrated on 08/18/2014, exceeding 5 years from this survey.

Failure to 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 one (1) of numerous tests and maintenance items of the automatic sprinkler system. The automatic sprinkler system serves the entire building.

The facility failed to provide a fire safety plan as required.

A written health care occupancy fire safety plan shall provide for 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
19.7.2.2

Observation and policy review determined the fire safety plan did not provide for the emergency phone call to fire department as required.

Failure to provide a fire plan as required increases the risk of death or injury due to fire.

The deficiency affected the required fire safety plan for the entire facility.

The facility failed to conduct fire drills as required.

Fire drill records review determined:

1) No fire drills were conducted on the Second Shift during the first and fourth quarter of 2019.

2) Fire drills did not include the simulation of an emergency phone call to the fire department in the past year.

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

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

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 areas other than kitchens where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. NFPA 70, 210.8, 210.8(A)(7)

The facility failed to provide electrical wiring and equipment in accordance with NFPA 70, National Electrical Code.

Observation determined electrical receptacles throughout the facility were installed within 6 ft. of a sink and 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 numerous receptacles throughout the facility.

Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standards for Health Care Facilities. 19.3.2.4

Electrical devices should be physically protected, such as by use of a protective barrier around the electrical devices, or by location of the electrical device such that it will avoid causing physical damage to the cylinders or containers. For example, the device could be located at or above 1.5m (5 ft) above finished floor or other location that will not allow the possibility of the cylinders or containers to come into contact with the electrical device as required by this section. NFPA 99, A.5.1.3.3.2(5)

The facility failed to ensure nonflammable medical gas equipment and systems were in compliance with NFPA 99. In oxygen storage rooms containing more than 300 cu. ft. of gas, all electrical wall fixtures must be physically protected or located at least five (5) feet above the floor.

Observation determined the Oxygen Storage Room contained over 300 cu. ft. of oxygen and had a light switch that was unprotected and installed less than five (5) feet above the floor.

This deficiency affected one (1) of one (1) oxygen storage room in the facility.