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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 90-minute annual test of the emergency battery back-up lights in the past year.

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 in the building.

The facility failed to install cooking equipment in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

A readily accessible means for manual activation shall be located between 1067 mm and 1219 mm (42 in. and 48 in.) above the floor, be accessible in the event of a fire, be located in a path of egress, and clearly identify the hazard protected. 19.3.2.5.1, 9.2.3, NFPA 96 10.5.1.

Observation determined the manual actuation device for the fire-extinguishing system serving the Kitchen exhaust hood was mounted at a height of more than forty-eight (48) inches above the floor. The manual pull was 56 inches above the floor.

Failure to inspect, maintain, and install the wet chemical extinguishing system in accordance with NFPA 96 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.

The facility failed to install alcohol-based hand rub dispensers in accordance with 8.7.3.1.

Observation determined an alcohol-based hand rub dispenser in Emergency Room 1 was located directly above a light switch.

Failure to install alcohol-based hand rub dispensers in accordance with 8.7.3.1 increases the risk of injury or death due to fire.

This deficiency affected one (1) of numerous dispensers in the facility.

The power source of non-power-limited fire alarm circuits shall comply with Chapters 1 through 4, and the output voltage shall be not more than 600 volts, nominal. The fire alarm circuit disconnect shall be permitted to be secured in the "on" position. NFPA 70, National Electrical Code. 760.41(A)

The branch circuit supplying the fire alarm equipment(s) shall supply no other loads. The location of the branch-circuit overcurrent protective device shall be permanently identified at the fire alarm control unit. The circuit disconnecting means shall have red identification, shall be accessible only to qualified personnel, and shall be identified as "FIRE ALARM CIRCUIT." The red identification shall not damage the overcurrent protective devices or obscure the manufacturer's markings. NFPA 70 760.41(B)

The facility failed to ensure the fire alarm system was in compliance with NFPA 70.

Observation determined the electrical circuit breaker providing power to the fire alarm system was not secured in the "on" position.

Failure to secure the electrical circuit breaker for the fire alarm system in the "on" position increases the risk of injury or death due to fire.

This deficiency affected the entire facility. The fire alarm system serves the entire building.

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 03/02/2022. 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.

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.

No record was available to determine the control valves and gauges of the automatic sprinkler system had been inspected during 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.

Portable fire extinguishers shall be provided in all health care occupancies. Extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 19.3.5.12, 9.7.4.1

Fire extinguishers having a gross weight not exceeding 40 lb. (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb. (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm). NFPA 10 6.1.3.8.1, 6.1.3.8.2, 6.1.3.8.3

The facility failed to install fire extinguishers in accordance with NFPA 10.

Observation determined portable fire extinguishers throughout the facility were installed with the top of the extinguisher more than 5 ft. above the floor.

Failure to install fire extinguishers in accordance with NFPA 10 increases the risk of injury or death due to fire.

The deficiency affected numerous fire extinguishers in the facility.

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 an electrical receptacle in the Radiology was installed within 6 ft. of a sink and was 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 one of numerous receptacles in the facility.