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Based on observation and interview the facility failed to ensure battery-operated lighting was located at generator and transfer switch locations as required according to National Fire Protection Association (NFPA) standards. This condition affected three (3) of three (3) smoke compartments, staff, patients, and other occupants of the building. The facility has the capacity for 25 beds.
The findings include:

Observation and interview on 04/16/14 at 10:40 AM with the Director of Maintenance (DOM) at the generator transfer switch revealed no battery-operated lighting in the room. The Director was unaware that emergency battery-operated lighting was required to be at generator and transfer switch locations. This type of lighting provides lighting to maintenance personnel at generator set and transfer switch locations in case the generator fails to start during a power failure.

The Administrator was not available for the exit interview. The DOM stated he would inform the Administrator of these findings.

Reference: NFPA 110 (1999 Edition).

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Reference: NFPA 101 (2000 Edition).

7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on observation and interview the facility failed to ensure battery operated lighting was located at generator and transfer switch locations as required according to National Fire Protection Association (NFPA) standards. This condition affected four (4) of four (4) smoke compartments, staff, patients, and other occupants of the building. The facility has a capacity for 25 beds.
The findings include:

Observation and interview on 04/16/14 at 10:40 AM with the Director of Maintenance (DOM) at the generator transfer switch revealed no battery-operated lighting in the room. The Director was unaware that emergency battery-operated lighting was required to be at generator and transfer switch locations. This type of lighting provides lighting to maintenance personnel at generator set and transfer switch locations in case the generator fails to start during a power failure.

The Administrator was not available for the exit interview. The DOM stated he would inform the Administrator of these findings.

Reference: NFPA 110 (1999 Edition).

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Reference: NFPA 101 (2000 Edition).

7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on interview and record review, the facility failed to maintain the fire alarm system by National Fire Protection Agency (NFPA) standards. This deficient practice affected four (4) of four (4) smoke compartments, staff, and other occupants of the building. The facility has the capacity for 25 beds.

The findings include:

An interview and record review on 04/16/14 at 10:50 AM, with the Director of Maintenance (DOM), revealed no record of sensitivity testing of the smoke/heat detectors. The DOM was unsure when this testing was last completed but stated he would contact the fire alarm company and send this information to the survey agency. This type of testing is due every two years to ensure the smoke/heat detectors are operating as intended. Documentation sent showed sensitivity testing was last performed on 06/23/11.

The Administrator was not available for the exit interview. The DOM stated he would notify the Administrator of the findings.

Reference: NFPA 72 (1999 Edition).

7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.
7-3.2.2
Test frequency of interfaced equipment shall be the same as specified by the applicable NFPA standards for the equipment being supervised.
7-3.2.3
For restorable fixed-temperature, spot-type heat detectors, two or more detectors shall be tested on each initiating circuit annually. Different detectors shall be tested each year, with records kept by the building owner specifying which detectors have been tested. Within 5 years, each detector shall have been tested.

Based on interview and record review, the facility failed to maintain the fire alarm system by National Fire Protection Agency (NFPA) standards. This deficient practice affected three (3) of three (3) smoke compartments, staff, and other occupants of the building. The facility has the capacity for 25 beds.

The findings include:

An interview and record review on 04/16/14 at 10:50 AM, with the Director of Maintenance (DOM), revealed no record of sensitivity testing of the smoke/heat detectors. The DOM was unsure when this testing was last completed but stated he would contact the fire alarm company and send this information to the survey agency. This type of testing is due every two years to ensure the smoke/heat detectors are operating as intended. Documentation sent showed sensitivity testing was last performed on 06/23/11.

The Administrator was not available for the exit interview. The DOM stated he would inform the Administrator of these findings.

Reference: NFPA 72 (1999 Edition).

7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.
7-3.2.2
Test frequency of interfaced equipment shall be the same as specified by the applicable NFPA standards for the equipment being supervised.
7-3.2.3
For restorable fixed-temperature, spot-type heat detectors, two or more detectors shall be tested on each initiating circuit annually. Different detectors shall be tested each year, with records kept by the building owner specifying which detectors have been tested. Within 5 years, each detector shall have been tested.

Based on record review, the facility failed to maintain its sprinkler system by National Fire Protection Agency (NFPA) standards. This condition affected three (3) of three (3) smoke compartments, staff, patients, and other occupants of the building. The facility has a capacity for 25 beds.

The findings include:

A record review on 04/16/14 at 12:15 PM with the Director of Maintenance (DOM), revealed no documentation that the sprinkler systems gauges were being maintained. The DOM was unaware the gauges to the sprinkler system had to be replaced or recalibrated every five years. This type of testing helps ensure the sprinkler system operates as intended.

The Administrator was not available for the exit interview. The DOM stated he would inform the Administrator of these findings.

Reference: NFPA 25 (1998 Edition).

2-3.2* Gauges. Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
2-2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

Based on observation and interview the facility failed to ensure battery-operated lighting was located at generator and transfer switch locations as required according to National Fire Protection Association (NFPA) standards. This condition affected three (3) of three (3) smoke compartments, staff, patients, and other occupants of the building. The facility has the capacity for 25 beds.
The findings include:

Observation and interview on 04/16/14 at 10:40 AM with the Director of Maintenance (DOM) at the generator transfer switch revealed no battery-operated lighting in the room. The Director was unaware that emergency battery-operated lighting was required to be at generator and transfer switch locations. This type of lighting provides lighting to maintenance personnel at generator set and transfer switch locations in case the generator fails to start during a power failure.

The Administrator was not available for the exit interview. The DOM stated he would inform the Administrator of these findings.

Reference: NFPA 110 (1999 Edition).

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Reference: NFPA 101 (2000 Edition).

7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on observation and interview the facility failed to ensure battery operated lighting was located at generator and transfer switch locations as required according to National Fire Protection Association (NFPA) standards. This condition affected four (4) of four (4) smoke compartments, staff, patients, and other occupants of the building. The facility has a capacity for 25 beds.
The findings include:

Observation and interview on 04/16/14 at 10:40 AM with the Director of Maintenance (DOM) at the generator transfer switch revealed no battery-operated lighting in the room. The Director was unaware that emergency battery-operated lighting was required to be at generator and transfer switch locations. This type of lighting provides lighting to maintenance personnel at generator set and transfer switch locations in case the generator fails to start during a power failure.

The Administrator was not available for the exit interview. The DOM stated he would inform the Administrator of these findings.

Reference: NFPA 110 (1999 Edition).

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Reference: NFPA 101 (2000 Edition).

7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on interview and record review, the facility failed to maintain the fire alarm system by National Fire Protection Agency (NFPA) standards. This deficient practice affected four (4) of four (4) smoke compartments, staff, and other occupants of the building. The facility has the capacity for 25 beds.

The findings include:

An interview and record review on 04/16/14 at 10:50 AM, with the Director of Maintenance (DOM), revealed no record of sensitivity testing of the smoke/heat detectors. The DOM was unsure when this testing was last completed but stated he would contact the fire alarm company and send this information to the survey agency. This type of testing is due every two years to ensure the smoke/heat detectors are operating as intended. Documentation sent showed sensitivity testing was last performed on 06/23/11.

The Administrator was not available for the exit interview. The DOM stated he would notify the Administrator of the findings.

Reference: NFPA 72 (1999 Edition).

7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.
7-3.2.2
Test frequency of interfaced equipment shall be the same as specified by the applicable NFPA standards for the equipment being supervised.
7-3.2.3
For restorable fixed-temperature, spot-type heat detectors, two or more detectors shall be tested on each initiating circuit annually. Different detectors shall be tested each year, with records kept by the building owner specifying which detectors have been tested. Within 5 years, each detector shall have been tested.

Based on interview and record review, the facility failed to maintain the fire alarm system by National Fire Protection Agency (NFPA) standards. This deficient practice affected three (3) of three (3) smoke compartments, staff, and other occupants of the building. The facility has the capacity for 25 beds.

The findings include:

An interview and record review on 04/16/14 at 10:50 AM, with the Director of Maintenance (DOM), revealed no record of sensitivity testing of the smoke/heat detectors. The DOM was unsure when this testing was last completed but stated he would contact the fire alarm company and send this information to the survey agency. This type of testing is due every two years to ensure the smoke/heat detectors are operating as intended. Documentation sent showed sensitivity testing was last performed on 06/23/11.

The Administrator was not available for the exit interview. The DOM stated he would inform the Administrator of these findings.

Reference: NFPA 72 (1999 Edition).

7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.
7-3.2.2
Test frequency of interfaced equipment shall be the same as specified by the applicable NFPA standards for the equipment being supervised.
7-3.2.3
For restorable fixed-temperature, spot-type heat detectors, two or more detectors shall be tested on each initiating circuit annually. Different detectors shall be tested each year, with records kept by the building owner specifying which detectors have been tested. Within 5 years, each detector shall have been tested.

Based on record review, the facility failed to maintain its sprinkler system by National Fire Protection Agency (NFPA) standards. This condition affected three (3) of three (3) smoke compartments, staff, patients, and other occupants of the building. The facility has a capacity for 25 beds.

The findings include:

A record review on 04/16/14 at 12:15 PM with the Director of Maintenance (DOM), revealed no documentation that the sprinkler systems gauges were being maintained. The DOM was unaware the gauges to the sprinkler system had to be replaced or recalibrated every five years. This type of testing helps ensure the sprinkler system operates as intended.

The Administrator was not available for the exit interview. The DOM stated he would inform the Administrator of these findings.

Reference: NFPA 25 (1998 Edition).

2-3.2* Gauges. Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.
2-2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.