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Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches inside three of three medication rooms. The facility census was 7

1. Observations on 1/23/18 and 1/29/18 during the facility tour showed the 1st, 2nd, and 3rd floor medication rooms controlled by a light switch:


During an interview on 1/23/18 at 10:06 A.M., the Chief Engineer stated medication room emergency lighting are controlled by switches.


NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses ' stations (unless adequately lighted by corridor
luminaires)
(4) Additional specialized patient care task illumination and
receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on observation and interview, the facility failed to install a sprinkler system in accordance with the National Fire Protection Association 13, Standards for the Installation of Sprinkler Systems. These deficient practices affects all patients in the facility. The facility census was 75.



1. Observation on 1/23/18, during the facility tour, showed five of five elevator hoistway pits did not have sprinkler coverage. Observation showed all six elevators employ a hydraulic elevator lift mechanism that uses a petroleum-based hydraulic fluid, which is combustible.

During an interview on 1/23/18 at 11:22 A.M., the Chief Engineer said that the elevator hoistway pits did not have sprinkler coverage.

Section 8.15.5.1* of NFPA 13 states: " Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.

* The sprinklers in the pit are intended to protect against fires caused by debris, which can accumulate over time. Ideally, the sprinklers should be located near the side of the pit below the elevator doors, where most debris accumulates. However, care should be taken that the sprinkler location does not interfere with the elevator toe guard, which extends below the face of the door opening.
ASME A17.1, Safety Code for Elevators and Escalators, allow the sprinklers within 2 ft (0.65 m) of the bottom of the pit to be exempted from the special arrangements of inhibiting waterflow until elevator recall has occurred.