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The facility failed to test and maintain the wet chemical extinguishing system in the Kitchen in accordance with NFPA 17A, Standard for Wet Chemical Extinguishing Systems.

On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual. 7.2.1

At a minimum, this quick check or inspection shall include verification of the following:

1) The extinguishing system is in its proper location.
2) The manual actuators are unobstructed.
3) The tamper indicators and seals are intact.
4) The maintenance tag or certificate is in place.
5) No obvious physical damage or condition exists that might prevent operation.
6) The pressure gauge, if provided, shall be inspected physically or electronically to ensure it is in the operable range.
7) The nozzle blowoff caps, where provided, are intact and undamaged.
8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated. 7.2.2

Review of documentation and interview with staff determined the monthly inspections of the wet chemical extinguishing system in the Kitchen had not been completed in the past year. An outside company did conduct semi-annual inspections of the system.

Failure to conduct monthly inspections of the wet chemical extinguishing system 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.

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, Table 14.4.5

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 on 04/01/2019. Records did not indicate any other load voltage test on the fire alarm system batteries in the past 8 months, exceeding the allowable frequency for semiannual tests.

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.

In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1, A.17.7.4.1

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined a smoke detector located in the corridor near the Medical Records Office was mounted on the ceiling within 36 in. of an air diffuser.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected one (1) of numerous smoke detectors in the 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 a portable fire extinguisher in the LAB was 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 one (1) of numerous fire extinguishers in the facility.

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 fire drills did not include the simulation of an emergency phone call to the fire department.

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.

The facility failed to ensure the emergency generator was in compliance with NFPA 99, Standard for Health Care Facilities.

A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:
1) Individual visual signals shall indicate the following:
a) When the emergency or auxiliary power source is operating to supply power to load
b) When the battery charger is malfunctioning
2) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
a) Low lubricating oil pressure
b) Low water temperature
c) Excessive water temperature
d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply
e) Overcrank (failed to start)
f) Overspeed
NFPA 99 6.4.1.1.17

Observation determined there was no remote annunciator located at a work site readily observable by personnel.

Failure to ensure the emergency generator was in compliance with NFPA 99 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.

Cylinders shall be protected from damage by means of the following specific procedures:
(1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
(2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them.
(3) Cylinders shall be protected from tampering by unauthorized individuals.
(4) Cylinders or cylinder valves shall not be repaired, painted, or altered.
(5) Safety relief devices in valves or cylinders shall not be tampered with.
(6) Valve outlets clogged with ice shall be thawed with warm - not boiling - water.
(7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device.
(8) Sparks and flame shall be kept away from cylinders.
(9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them.
(10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1.
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
(12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts. NFPA 99, 11.6.2.3.

The facility failed to protect oxygen cylinders as required by NFPA 99.

Observation determined a freestanding oxygen cylinder in the Oxygen Storage Room was placed on the floor and not secured in a cart, stand, or chain.

Failure to secure oxygen cylinders increases the risk of injury or death due to fire.

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