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The emergency illumination lighting system must be arranged to provide the required illumination automatically. 7.9.2.2

Note: CMS allows a light fixture equipped with a single long-life bulb with a quick strike feature to illuminate exit discharge.

The facility failed to ensure the illumination of means of egress, including exit discharge, was arranged so that failure of a single lighting fixture (bulb) would not leave the area in darkness.

Observation determined the exterior of three (3) of the five (5) exits was illuminated with a single-bulb light fixture. The light fixtures that illuminated the north, northeast, and east central exit discharge areas were single-bulb light fixtures.

Visual inspection frequencies and specific testing and maintenance frequencies for smoke detection systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with the manufacturer's specifications.

Review of the fire alarm test results indicated the smoke detection system did not have sensitivity testing at frequencies in compliance with the minimum requirements of NFPA 72.

The test records indicated the smoke detectors were sensitivity tested in November, 2009. During the 2009 sensitivity test four smoke detectors failed the sensitivity test and were replaced in December, 2009. The facility failed to conduct a sensitivity test on the new smoke detectors within 365 days of installation.

The facility failed to inspect the emergency generator on a weekly basis.

Review of generator test records indicated that weekly inspections were not being documented.