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Based on review of facility schematics, facility observation, review of preventative maintenance documentation and staff Interview and confirmation, the facility failed to ensure: There must be emergency power and lighting in at least the operating, recovery, intensive care, and emergency rooms, and stairwells. In all other areas not serviced by the emergency supply source, battery lamps and flashlights must be available; and the hospital must maintain written evidence of regular inspection and approval by State or local fire control agencies. The facility capacity was 114 with a census of 71.

See Tags at A-0702 and A-0715.

Based on observation and staff interview, the facility failed to maintain its generator in accordance with NFPA 101-2012 Edition section 7.9.2.4, NFPA 110-2010 Edition sections 5.6.5.6 and 5.6.5.6.1. This deficient practice had the potential to affect all 127 residents in the facility.

Findings include:

On 06/11/2024 at 1:45 P.M., observation during the facility tour with the Director of Maintenance revealed the facility's generators were not equipped with remote manual stop stations.

The Director of Maintenance verified the above finding at the time of observation.

NFPA 101-2012 Edition,
7.9.2.4 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, other than battery systems for emergency luminaries in accordance with 7.9.2.5, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

NFPA 110-2010 Edition,
5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled.
A.5.6.5.6 For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Based on observations, record review the facility failed to ensure receptacles in resident rooms were tested in accordance with the LSC, 2012 Edition 7.9.2.4, 6.3.3.2. This deficient practice had the potential to affect all 127 residents in the facility.

Findings include:

On 06/11/2024 at 1:13 P. M., during record review the facility was unable to provide documentation showing completion of the required annual receptacle testing in patient care rooms.

The Director of Maintenance verified the above findings at the time of record review.

NFPA 101-2012 Edition,
7.9.2.4 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, other than battery systems for emergency luminaries in accordance with 7.9.2.5, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).