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Based on observation and interview, the Facility failed to ensure that fire sprinklers were intalled in accordance with NFPA 13.

Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 12:00 PM on 08/20/2019, it was discovered that the following areas were not protected by fire sprinklers:
1. Fire Sprinkler Riser Room
2. Pharmacy
3. Staff Kitchenette
4. Boiler Room

NOTE: Facility should conduct a facility wide assessment to ensure all areas of the hospital have the required fire sprinkler protection.

This deficient practice was verified by the Facility Maintenance Director.

Based on observation and interview, the Facility failed to maintain the fire sprinkler system in accordance with 9.7.5, 9.7.7, 9.7.8, and NFPA 25.

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Findings include:

On facility tour between 9:00 AM and 12:00 PM on 08/20/2019, it was revealed that the gauge on the fire sprinkler system was not replaced within the required 5 year period.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to conduct Fire Drills in accordnance with 18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7.

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7.

Findings include:

On facility tour between 9:00 AM and 12:00 PM on 08/20/2019, during documentation review and interview it was determined that a 2nd shift fire drill was not conducted during the 2nd and 3rd quarters. Also a 3rd shift fire drill was not conducted during the 4th quarter.

This deficient practice was verified by the Facility Maintenance Director.

Electrical Systems - Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99).

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 12:00 PM on 08/20/2019, it was revealed that the electric receptacles were not being tested on an annual basis. The electrical receptacles must receive the following inspections:

1.The physical integrity of each receptacle shall be confirmed by visual inspection.
2. The continuity of the grounding circuit in each electrical receptacle shall be verified.
3. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
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).

This deficient practice was verified by the Facility Maintenance Director.